n 


I 


BLOOD -PRESSURE 

FROM    THE    CLINICAL    STANDPOINT 


BY 

FRANCIS  ASHLEY  FAUGHT,  M.D. 

FORMERLY    DIRECTOR  OF   THE  LABORATORY  OF  CLINICAL  MEDICINE  AND 

INSTRUCTOR     IN     MEDICINE      AT     THE     MEDICO-CHIRURGICAL     COLLEGE, 

PHILADELPHLV 


SECOND  EDITION,  THOROUGHLY  REVISED 


PHILADELPHIA  AND  LONDON 

W.    B.   SAUNDERS    COMPANY 

1916 


\ 


Copyright,  IQ13,  by  W.  B.  Saunders  Company.    Reprinted  September,  1Q13, 

February,  1914,  and  July,  1914.     Revised,  entirely  reset,  reprinted, 

and  recopyrighted  September,  1916 


Copyright,  1916,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OP 

W.     B.     SAUNDERS     COMPANY 

PHILADELPHIA 


PREFACE  TO  SECOND  EDITION 


In  the  preparation  of  the  second  edition  of  this  Uttle 
work  the  author  has  adhered  to  the  plan  originally  outlined 
by  avoiding  wherever  possible  unnecessary  discussion  and 
the  introduction  of  theoretic  and  inconclusive  data. 

More  careful  methods  of  clinical  study  have  enabled  the 
author  to  introduce  a  larger  amount  of  clinical  material 
including  many  new  charts,  illustrative  of  various  types  of 
blood-pressure  changes,  from  which  it  is  hoped  that  the 
reader  may  be  able  to  acquire  a  more  practical  view  of  the 
subject. 

In  the  following  pages  the  purely  scientific  investigator 
should  not  be  too  critical  of  the  conclusions  drawn  but 
should  allow  the  author  considerable  latitude,  as,  through- 
out, the  chief  effort  has  been  to  reduce  a  very  large  and 
complicated  subject  to  a  practical  working  basis,  one  which 
may  be  applied  to  everyday  conditions,  which  after  all  is 
the  chief  concern  of  the  practitioner. 

For  valuable  assistance  rendered  in  the  preparation  of 
this  edition  the  author  desires  particularly  to  thank  Drs. 
George  P.  Miiller,  Francis  J.  Dever  and  Brooke  M. 
Anspach. 

Francis  Ashley  Faught. 

5006  Spruce  Street,  Philadelphia,  Pa. 
September,  1916. 


357638 


PREFACE 

The  past  few  years  have  marked  a  rapid  rise  in  the 
cUnical  value  of  the  sphygmomanometer.  This  instrument 
is  now  a  part  of  the  armamentarium  of  almost  every  physi- 
cian. It  is  opportune  therefore  that  a  book  of  moderate  size 
should  be  produced  containing  in  concise  form,  a  resum^ 
of  the  clinical  and  experimental  work  which  has  led  to  present 
popularity  of  the  blood-pressure  test. 

In  the  following  pages,  the  author  has  endeavored  to 
present  in  easily  accessible  form,  the  pith  of  medical  litera- 
ture bearing  on  blood-pressure  studies  in  their  relation  to 
medicine,  not  only  in  cardio-vascular  and  renal  conditions, 
but  also  in  many  diseases  in  which  clinical  observation 
has  shown  the  information  obtained  by  the  sphygmomano- 
meter to  be  of  value. 

It  has  been  thought  advisable  to  devote  a  number  of 
pages  to  the  discussion  of  the  circulation  and  its  relation 
to  the  blood-pressure,  together  with  the  various  methods 
employed  in  sphygmomanometry,  to  acquaint  the  prac- 
titioner with  the  theory  of  this  procedure,  so'  that  deduc- 
tions from  his  observations  may  be  of  greatest  value. 

The  writer  is  indebted  to  a  large  number  of  authors  for 
much  of  the  material  contained  in  this  work,  which  has 
been  obtained  largely  from  the  medical  literature  of  the 
last  seven  or  eight  years.  Whenever  practical  the  full 
reference  is  given  in  the  text,  so  that  if  desired,  the  facts 
contained  in  this  little  book  may  be  supplemented  by  a 
study  of  the  original. 

Feancis  Ashley  Faught. 

5006  Spruce  Street,  Philadelphia,  Pa. 


11 


CONTENTS 

Page 

Introduction 17 

CHAPTER  I 

Physiology 19 

The  Circulation 19 

Course  of  Circulation 22 

CHAPTER  II 

Terms  and  Definitions  Employed  in  Study  of  Arterial  Pressure.  36 

Blood-pressure 36 

Causes  of  Arterial  Pressure  and  Factors  in  Its  Maintenance  ...  43 

CHAPTER  III 

Principle  of  the  Sphygmomanometer 50 

Instrumental  Estimation  of  Blood-pressure 50 

Estimation  of  Blood-pressure 54 

Precautions  While  Using  Sphygmomanometer 56 

CHAPTER  IV 

The  Sphygmomanometer 62 

Method  of  Use  and  Description  of  Instruments 62 

Development  of  Sphygmomanometer 63 

Classification  of  Blood-pressure  Instruments 68 

Descriptions  of  Modern  Instruments 69 

CHAPTER  V 

Clinical  Determination  of  Blood-pressure 89 

A.  The  Auscultatory  Method 90 

B.  The  Palpatory  Method 102 

C.  The  Visual  Method 103 

D.  The  Graphic  Method 104 

E.  The  Oscillatory  Method 104 

CHAPTER  VI 

Normal  Blood-pressure;  Its  Variations  and  the  Physiologic  or 

Non-pathologic  Factors  Affecting  It 109 

The  Normal  Blood-pressure 112 

The  Normal  Variations  in  Systolic,  Diastolic  and  Pulse  Pressures.  113 

13 


14  CONTENTS 

CHAPTER  VII  Page 

Thb  PtTLSE  Pressure ,   .  135 

CHAPTER  VIII 

Venous  and  Capillary  Blood-pressure 142 

Venous  Blood -pressure 146 

The  Physics  and  Physiology  of  Venous  Blood-pressures 149 

CHAPTER  IX 
Climatologic  and  Racial  Influences 156 

CHAPTER  X 

Physical  Fitness,  Exercise  and  Athletics.     Their  Effect  upon 

AND  Relation  to  Blood-pressure 164 

Cardiac  Efficiency  in  Relation  to  Exercise 165 

CHAPTER  XI 
Blood-pressure  in  Children 183 

CHAPTER  XII 

Acute  Infections 187 

Toxemia  and  Blood-pressure 187 

Pneumonia 189 

Typhoid  Fever 194 

Diphtheria 197 

Scarlet  Fever 198 

Cholera 200 

Malaria 200 

Epidemic  Cerebrospinal  Meningitis 201 

Other  Acute  Infections 202 

CHAPTER  XIII 

Chronic  Infections 203 

Tuberculosis 203 

Syphilis 213 

CHAPTER  XIV 
Blood-pressure   in   Metabolic,   Neurologic  and    Miscellaneous 

Conditions 216 

Neurologic  Data 230 

CHAPTER  XV 
Hypotension 235 

CHAPTER  XVI 
Hypertension;  Hyperpiesis 243 

CHAPTER  XVII 

Arteriosclerosis 254 

Incidence  of  Arteriosclerosis 260 


CONTENTS  ^^ 

Paob 

261 
Etiology  of  Arteriosclerosis ^^^ 

Summary 267 

Pathology 269 

Clinical  Manifestations ^75 

Diagnosis 

CHAPTER  XVIII 

Nephritic  Hypertension  and  Chronic  Nephritis 282 

Theory  of  Mechanism  of  Production  of  High  Blood-pressure.    .    .  2«b 

Pathology  of  Nephritis ^95 

Symptomatology „q^ 

Diagnosis 04Q 

Prognosis g^g 

Summary ^^^ 

Treatment 

CHAPTER  XIX 
Cardiac  Disease:  Myocardial,  Valvular,  and  Functional.     Mto-  ^^^ 

cardial  Insufficiency 

Chronic  Valvular  and  Functional  Cardiac  Diseases ^^^ 

Aortic  Insufficiency „„g 

Mitral  Defects ^^^ 

Cardiac  Load  and  Overload 

CHAPTER  XX 

rtA'T 

Relation  op  Blood-pressure  to  Surgery 

AppUcation  of  Test  to  Surgical  Cases ^ 

Influence  of  Operative  Procedures 

Influence  of  Anesthetics  on  Blood-pressure ^^ 

Ophthalmologic  Data ^^^ 

Shock 

CHAPTER  XXI 

The  Blood-pressure  Test  in  Obstetrics 384 

Normal  Blood-pressure  during  Pregnancy ^°^ 

Effect  of  Labor  on  Blood-pressure 

Complications  Affecting  Blood-pressure  during  Pregnancy         .    •   d87 
Effects  of  Drugs  on  Blood-pressure  during  Pregnancy  and  Labor.   6\ib 
CHAPTER  XXII 
Blood-pressure  Estimations  in  Physical  Examinations  for  Life  ^^^ 

Insurance „_» 

Value  of  the  Test  in  Life  Insurance 

CHAPTER  XXIII 
Therapeutic    Value   of    Drugs   Affecting  Blood-pressure   and 
Those    Commonly    Employed    in    Cardiovascular    and    Renal 

40y 
Conditions .  .„ 

The  Nitrite  Group 


16  CONTENTS 

CHAPTER  XXIV  P.^ge 

Physical  Measures  Employed  in  the  Management  op  Conditions 

Presenting  Abnormal  Blood-pressure 436 

Physical  Measures 438 

Hydrotherapy 447 

Electrotherapy 455 

Venesection 460 


Index 461 


BLOOD-PRESSURE 

INTRODUCTION 

The  study  of  blood-pressure  is  unique  in  that  it  is  the 
only  subject  employing  a  method  of  precision  which  en- 
joys an  almost  universal  field  of  application,  and  that, 
unlike  other  clinical  investigations  which  require  special 
apparatus,  its  employment  is  not  confined  to  the  internist 
and  the  laboratory  worker.  The  blood-pressure  test 
being  easily  applied  and  the  results  more  than  satisfactory, 
it  has  rightly  found  general  favor  at  the  hands  of  widely 
varying  branches  of  the  healing  art. 

This  great  and  sudden  popularity  has  had  certain  draw- 
backs, as  a  tendency  has  been  created  in  some  directions 
to  jump  at  extreme  conclusions  regarding  the  value  or 
non-value  of  the  test,  so  that  either  unlimited  reliance 
has  been  placed  in  the  findings  to  the  elimination  of 
other  perhaps  equally  important  data,  or  the  value  of 
the  study  of  blood-pressure  has  not  been  adequately  con- 
sidered by  other  clinicians  who  as  a  result  have  failed  to  give 
their  patients  the  benefit  of  its  undoubted  advantages. 

In  spite  of  the  comparatively  recent  development  of 
this  test  in  its  present  form,  there  has  already  accumulated 
a  most  extensive  literature  making  it  almost  impossible  to 
keep  abreast  with  it.  The  author  has  in  this  work  endeav- 
ored to  collate  and  sift  out  the  many  points  of  value  on 
blood-pressure    found   in   recent    and   current    literature, 

2  17 


18  BLOOD-PRESSURE 

and  to  place  them  in  such  shape  that  the  busy  practitioner 
may  speedily  acquire  a  general  view  of  the  subject.  In 
so  doing,  the  author  has  been  forced,  for  reasons  of  economy 
of  space,  to  limit  the  discussion  to  certain  fixed  lines. 
Thus,  no  attempt  has  been  made  to  devote  great  space 
to  a  consideration  of  the  theoretical  and  experimental  sides 
of  the  subject,  either  from  the  physiologic  or  the  pathologic 
standpoint,  except  in  so  far  as  they  have  an  immediate 
and  practical  application.  It  was  thought  advisable, 
however,  to  insert  a  number  of  extra  references  for  the 
benefit  of  those  who  wish  to  consider  the  subject  more 
comprehensively. 

Neither  has  unnecessary  space  been  occupied  in  de- 
scribing the  large  number  of  blood-pressure  testing  in- 
struments, many  of  which  have  become  either  obsolete  or 
nearly  so,  while  others  vary  so  little  in  character,  design, 
or  in  operating  principle  that  detailed  description  was 
deemed  unnecessary.  Others  again  are  so  complicated  in 
mechanism  or  mode  of  operation  as  to  render  them  prac- 
tically without  value  in  clinical  medicine. 

The  preparation  of  this  revised  work  has  entailed  the 
reading  and  sifting  of  an  immense  amount  of  "literature" 
for  which  due  credit  has  been  given  to  the  authors,  when- 
ever practical;  while  the  great  volume  of  material  to  review 
has  increased  the  probability  of  inadvertent  omissions, 
which  are,  it  is  believed,  neither  many  or  serious. 

At  the  same  time  rules  for  the  admission  of  material 
have  had  at  times  to  be  closely  drawn  in  the  interests  of 
brevity,  that  perhaps  some  omissions  have  been  made 
which  may  perhaps  be  deplored  by  the  reader. 


CHAPTER  I 
PHYSIOLOGY 

THE  CIRCULATION 

As  practice  makes  perfect,  so  has  the  extended  and 
universal  appHcation  of  the  sphygmomanometer  perfected 
and  reduced  to  a  practical  basis  a  large  amount  of  theo- 
retical and  conjectural  material  bearing  on  blood-pressure 
which,  until  recently,  was  without  scientific  foundation. 
For  this  reason,  in  order  to  gain  a  proper  appreciation  of 
the  function  of  the  sphygmomanometer  and  the  relation 
of  blood-pressure  readings  of  systolic,  diastolic  and  pulse 
pressure,  to  the  changing  conditions  in  the  cardiovascular 
system  which  this  study  reveals,  it  is  primarily  essential 
to  possess  a  working  knowledge  of  the  theory  of  hydro- 
statics, and  its  relation  to  the  human  physiology,  to- 
gether with  its  modification  by  physical  and  vital  condi- 
tions surrounding  the  human  circulation  both  in  health 
and  disease.  It  is  only  by  the  knowledge  of  at  least  the 
essentials  of  this  subject,  that  a  proper  appreciation  of  the 
factors  controlling  the  cardiovascular  system  in  both 
health  and  disease  and  the  relation  of  this  system  to  the 
kidneys  and  other  organs  closely  associated  with  it  can 
be  had.  It  is  proper,  therefore,  to  preface  a  clinical 
study  of  blood-pressure  with  a  brief  general  discussion  of 
the  circulation,  even  though  to  so  do  may  seem  to  some 
to  be  a  needless  waste  of  time  and  space. 

19 


20  BLOOD-PRESSURE 

General  Considerations. — The  maintenance  of  a  normal 
circulation  is  essential  to  health.  Permanent  (and  tran- 
sient also)  alterations  in  the  circulation  are  either  the 
result  of  disease,  or  result  in  it.  The  action  of  the  heart 
is  a  vital  function  like  respiration,  for  if  the  heart  should 
cease  to  beat  even  for  a  very  short  space  of  time,  the 
circulation  would  fail,  and  the  individual  would  die. 
The  heart  must  not  only  act  continuously,  but  it  must  also 
perforip  its  function  in  an  approximately  normal  manner 
in  order  to  maintain  a  normal  circulation  which  is  essential 
to  health. 

Conditions  affecting  the  action  of  the  heart  are  fre- 
quently shown  by  alterations  in  the  circulation,  and 
variations  in  the  circulation  may  often  be  shown  by  changes 
in  the  heart's  action.  Failure  of  the  circulation  is  ac- 
companied by  a  gradual  diminution  in  blood-pressure, 
until  it  becomes  insufficient  to  maintain  body  nutrition 
and  offers  insufficient  resistance  for  a  normal  action  of 
the  heart.  The  two  conditions,  heart  action  and  a  main- 
tained circulatory  equilibrium,  are  in  every  way  inter- 
dependent. They  can  neither  be  separated,  nor  con- 
sidered intelligently,  one  apart  from  the  other.  This 
serves  to  emphasize  the  importance  of  a  study  of  the 
circulation,  not  only  in  an  investigation  of  circulatory 
diseases  and  cardiac  affections  but  also  in  the  study  of 
diseases  of  practically  any  part  of  the  body  including  those 
of  infectious  and  metabolic  origin. 

We  are  for  the  most  part  indebted  to  Harvey^  for 
discovering  and  demonstrating  the  true  function  of  the 

'  Sec  Cainac's  "Epoch-making  Contributions  to  Medicine  and  Surgery," 
Philadelphia,  1909. 


PHYSIOLOGY  21 


heart  as  the  mainspring  of  the  circulation.     In  1616,  Wm. 
Harvey  stated  that  ''a  perpetual  movement  of  the  blood 
in  a  circle  is  caused  by  the  beat  of  the  heart."     It  is 
evident  that  Harvey's  conception  was  the  true  one,  as  it 
forms  the  basis  of  our  modern  theory  of  circulatory  physi- 
ology and  pathology.     It  is  of  interest  to  note,  however, 
that   investigations   of   ancient   manuscripts,   bearing   on 
medicine,  show  that  some  knowledge  of  the  circulation 
of  the  blood  was  possessed  by  the  ancient  Egyptians  as 
shown  by  references  to  the  heart,  and  the  use  of  the  word 
''circulate"  in  the  Ebers  papyrus.     In  this  connection  an 
interesting  review  ''The  Advance  in  Knowledge  Regarding 
the  Circulation  of  the  Blood"  has  recently  been  published 
by  Dr.  Geo.  Wm.  Norris. 

The  Normal  Circulation.— Broadly  speaking,  it  may  be 
said  that  the  term  normal  circulation  presupposes  a  normal 
blood-pressure   maintained   by   a   normally   acting  heart 
with  normal  vessels  and,  as  a  corollary,  abnormal  blood- 
pressure  is  an  indication  of  some  abnormality  in  the  cir- 
culation.    Were  this  in  every  sense  true  in  practice,  the 
whole   study   of   blood-pressure   and   its   relation   to   the 
pathology  of  the  circulation  would  be  a  simple  and  open 
book.     When  viewed  from  the  standpoint  of  the  human 
organism,  involving  as  it  does  many  complex  and  inter- 
related mechanisms,  which  are  in  turn  affected  both  by 
internal   and   external   conditions   it   is   evident   that   so 
many  factors  must  enter  into  this  consideration,  that  we 
are  forced  to  the  conclusion  that  the  study  is  a  compUcated 
one,  which  can  only  be  understood  by  a  most  careful  con- 
sideration of  the  sum  of  many  internal  and  external  influ- 
ences affecting  the  cardiovascular  system  and  the  kidneys. 


22 


BLOOD-PRESSURE 


COURSE    OF    THE    CIRCULATION 

In  the  human  body  we  may  trace  the  course  of  a  given 
particle  of  blood  as  it  leaves  the  right  ventricle  until,  hav- 
ing traversed  the  entire  cardiovascular  system,  it  returns 
to  the  starting-point.     Referring  to  Fig.  1,  we  find   the 

course  of  the  blood  to  be 
as  follows:  From  the 
trunk  of  the  pulmonary 
artery  through  a  succes- 
sion of  arterial  branches 
into  the  capillaries  of  the 
lungs,  from  there  through 
the  several  branches  of 
the  pulmonary  vein  to 
the  left  auricle  of  the 
heart,  thence  through 
the  mitral  valve  to  the 
left  ventricle,  then  by 
way  of  the  aortic  valve 
to  the  aorta  and  the 
general  arterial  tree  until 
it  finally  reaches  the 
capillaries.  From  the 
capillaries  into  the  veins 
back  toward  the  heart 
through  the  venae  cavse  and  into  the  right  ventricle, 
through  the  pulmonary  valve  into  the  pulmonary  artery 
where  the  tracing  of  the  circuit  began. 

The  physiologic  factors  controlling  the  normal  changes 
in  the  circulation  have  been  carefully  studied  and  sum- 


FiG.  1. — General  diagram  of  the  circu- 
lation: the  arrows  indicate  the  course  of 
the  blood:  PA,  pulmonary  artery;  PC, 
pulmonary  capillaries;  PV,  pulmonary 
veins;  LA,  left  auricle;  LV,  left  ventricle; 
A,  systemic  arteries;  C,  systemic  capil- 
laries; V,  systemic  veins;  RA,  right  auri- 
cle; RV,  right  ventricle.  (John  G.  Curtis 
in  "  American  Text-book  of  Physiology.") 


PHYSIOLOGY  23 

marized  by  Gibson^  who  states  that  the  circulation,  in 
the  higher  animals  including  man,  is  based  upon  four 
primary  groups  of  principles:  (1)  Mechanical  arrange- 
ment; (2)  chemical  changes;  (3)  glandular  secretions;  and 
(4)  adjustment  of  nervous  agencies;  and  that  these  four 
principles  are  capable  of  most  complicated  interrelation. 
A  proper  adjustment  between  them  is  maintained  in  health 
and  is  responsible  for  a  normal  circulation. 

1,  Mechanical  Arrangements. — We  find  that  these  com- 
prise: (a)  the  vascular  system,  which  is  a  closed  series  of 
tubes  (arteries  and  veins)  of  varying  diameters;  (6)  the 
heart,  which  mechanically,  is  an  intermittent  force  pump, 
interposed  between  the  largest  veins  on  one  side  and  the 
largest  arteries  on  the  other.  This  tubular  system  is 
partially  interrupted  at  two  points  by  a  series  of  very 
minute  vessels  (c)  the  capillaries  of  the  lungs  and  of  the 
general  circulation. 

The  condition  of  the  arterial  walls  and  the  width  of  the 
arteries  exercise  considerable  influence  upon  the  flow  of 
blood.  If  all  the  arteries  were  fully  dilated  it  would  be 
absolutely  impossible  for  the  heart  to  maintain  the  cir- 
culation, because  the  relatively  small  amount  of  blood  in 
the  body  could  not  begin  to  completely  fill  the  vessels. 

The  force  by  which  the  blood  is  driven  from  the  right 
to  the  left  side  of  the  heart,  through  the  capillaries  which 
are  related  to  the  respiratory  surface  of  the  lung,  is  nearly  all 
derived  from  the  contraction  of  the  muscular  wall  of  the 
right  ventricle.  The  force  by  which  the  blood  is  driven 
from  the  left  side  of  the  heart  through  the  general  circula- 
tion,  including  all  the  other  capillaries  in  the  body,  is 

^Brit.  Med.  Jour.,  July  27,  Vol.  2,  No.  2691. 


24  BLOOD-PRESSURE 

nearly  all  derived  from  the  contractions  of  the  muscular 
wall  of  the  left  ventricle.  The  contraction  of  the  two  ven- 
tricles is  simultaneous.  The  force  generated  by  the  heart 
in  maintaining  the  circulation  is,  to  a  subordinate  degree, 
supplemented  by  the  aspirating  action  of  the  chest  wall 
during  the  respiratory  act,  by  the  pumping  action  of  the 
skeletal  muscles  and  by  the  elasticity  or  tone  of  the  arteries 
themselves. 

The  usual  systolic  arterial  blood-pressure,  which  varies 
between  110  and  140  mm.  Hg.,  is  much  more  than  is 
actually  necessary  to  drive  blood  from  the  arteries  into  the 
veins.  This  extra  pressure  has  a  function,  however,  which 
is  seen  whenever  the  arterioles  of  any  organ  or  small  area 
relax.  If  the  arterial  pressure  was  barely  adequate  to 
sustain  a  flow,  a  lowered  resistance  in  any  part  would 
seriously  drain  other  regions.  The  high  head  of  pressure, 
therefore,  serves  to  keep  all  parts  properly  supplied  with 
blood,  even  if  an  especially  active  part  of  the  body  is 
making  an  unusual  demand. 

In  order  to  better  understand  the  mechanical  arrange- 
ment of  the  cardiovascular  system  it  is  necessary  first, 
to  consider  the  science  of  hydrostatics  as  to  its  effect  upon 
the  circulatory  system. 

■  Fluids  are  incompressible  and  the  heart  is  an  intermittent 
pump;  therefore  if  the  arteries  were  rigid  and  unyielding 
tubes,  each  increment  of  blood  coming  from  the  heart 
would  be  required  to  move  all  the  blood  in  the  whole 
arterial  system,  while  during  the  heart-rest,  all  flow  would 
cease.  This  would  result  in  the  intermittent  develop- 
ment of  pressure,  accompanied  by  periods  when  it  must 
fall  to  zero.     Such  a  condition  would  be  inimical  to  health, 


PHYSIOLOGY  25 

as  the  proper  nutrition  and  tension  of  the  organs  and 
tissues  of  the  body  would  not  be  maintained.  The  arterial 
walls  are,  however,  as  already  stated,  not  rigid  but  elastic 
and  distensible,  and  are  capable,  therefore,  of  expanding 
under  pressure  to  accommodate  more  fluid,  while  during 
diastole  their  elasticity  and  contractility  tend  to  maintain 
pressure.  This  property  gradually  reduces  the  sharp 
intermittency  of  the  flow  in  the  arterial  system,  so  that,  as 
we  pass  outward  from  the  heart,  this  feature  becomes  less 
marked  and  finally  disappears  before  the  capillaries  are 
reached.  Another  factor  enters  here.  This  is  the  gradual 
tapering  and  extensive  ramification  of  the  arterial  system. 
The  length  of  vessels  combined  with  their  elasticity  further 
aid  in  reducing  this  intermittency  to  a  uniform  current. 

A  third  factor  is  the  relatively  large  number  and  minutely 
small  diameter  of  the  capillaries.  If  the  vessels  were 
short  and  the  tubes  of  large  diameter  the  flow  would  pass 
into  the  veins  intermittently.  This  is  seen  in  certain 
pathologic  conditions  where  we  have  a  capillary  pulse  and 
a  transmitted  venous  pulse. 

In  considering  the  capillaries,  we  find  that  they  also 
assist  in  maintaining  blood-pressure,  for  if  the  heart  as  a 
pump  was  large  enough  and  the  arteries  short  enough  and 
the  outlet  large  enough  there  would  be  no  blood-pressure. 

Starting  with  the  arterial  system  as  a  closed  system  of 
tubes,  including  the  heart,  we  find  that  as  the  heart  begins 
to  beat,  blood  is  pumped  into  the  arteries,  and  in  its 
passage  toward  the  capillaries  it  meets  with  resistance. 
This  causes  the  pressure  to  rise  in  the  arterial  system. 
This  increase  in  pressure  brings  into  action  the  elasticity 
of  the  arterial  walls,   so  that  as  the  pressure  rises   the 


26  BLOOD-PRESSURE 

arteries  expand  to  accommodate  an  additional  amount  of 
blood,  at  the  same  time  the  blood-pressure  rises;  this  in- 
creases the  pressure  in  the  capillary  system  and  drives 
more  blood  into  the  veins  in  a  given  time.  Blood-pressure 
will  reach  normal  and  be  maintained  there,  when  the 
amount  of  blood  passing  through  the  capillaries  during  a 
heart  cycle  equals  the  amount  entering  the  aorta  during 
systole.  At  this  time,  the  power  of  the  heart  is  exactly 
balanced  by  the  resistance  in  the  arterial  system  and  a 
level  of  pressure  is  established. 

The  mechanical  arrangement  of  the  circulation,  there- 
fore, provides  for  the  general  distribution  of  blood  to  all 
parts  of  the  body,  through  the  agency  of  the  heart,  the 
arteries,  the  capillaries  and  the  veins  and,  in  addition, 
provides  for  the  conversion  of  an  intermittent  cardiac 
output  into  a  uniform  flow  in  the  confines  of  the  arterial 
tree. 

2.  The  Chemical  Changes. — Our  knowledge  of  the  chem- 
ical changes  taking  place  in  the  circulation  and  their 
relation  to  the  control  of  blood-pressure  is  but  limited. 
It  involves  a  knowledge  and  consideration  of  the  effect  of 
the  catalytic  action  on  a  number  of  substances  of  a  com- 
plex organic  nature,  whose  function  it  is,  at  least  in  part, 
to  preserve  the  normal  composition  of  the  blood  and  to 
control  and  regulate  the  normal  interchange  of  gases 
in  the  capillaries  of  the  lungs,  and  of  pabulum  and  waste 
materials  in  the  systemic  capillaries  and  tissue  spaces. 

The  chemical  regulation  is  probably  maintained  through 
the  agency  of  certain  substances,  acting  upon  the  vaso- 
motor system  and  on  the  arterial  lining.  Thus  the  work 
of  H.  A.  Stewart  and  S.  C.  Harvey  appears  to  demonstrate 


PHYSIOLOGY  27 

the  presence  of  a  vasodilator  substance,  of  probably 
proteid  nature,  which  is  specific  for  the  renal  vessels. 
They  state  further  that  these  substances  appear  to  act 
both  directly  upon  the  muscular  coat  of  the  vessels,  and 
also  through  the  vasomotor  centers  of  the  medulla. 

It  has  been  suggested  that  the  carbon  dioxide  and  lactic 
acid  liberated  during  muscular  activity  play  a  part  in  this 
regulating  mechanism. 

R.  M.  Pearce^  experimenting  with  the  extracts  of 
kidneys  of  various  animals  has  demonstrated  a  mixed 
chemical  action,  in  that  these  extracts  may  either  diminish 
or  increase  blood-pressure,  thereby  differing  in  their  effect 
from  extracts  of  the  adrenals  (see  below).  He  also  found 
that  there  was  no  difference  in  the  effect  of  extracts  of 
normal  kidneys  as  compared  with  those  which  were  the 
seat  of  different  forms  of  nephritis.  R.  Mohr^  has  demon- 
strated that  an  increase  in  these  substances  may  produce 
sudden  and  serious  drops  in  pressure,  as  noted  previously 
by  Sabatowski. 

Closely  related  to,  and  possibly  dependent  partly  upon, 
chemical  changes  in  the  blood,  is  the  effect  of  the  inter- 
change of  fluids  between  the  blood-vascular  and  the 
lymph-vascular  systems  and  the  tissues  of  the  body. 
While  this  is  undoubtedly  in  part  controlled  by  the  special 
vasomotor  system,  nevertheless  it  is  not  unreasonable  to 
suppose  that  changes  in  the  chemical  composition  of  the 
blood  affect  the  relative  amount  of  and  distribution  of 
blood  and  lymph  in  the  human  body,  while  it  is  well 
known  that  abnormal  substances,   particularly  bacterial 

^Jour.  Exp.  Med.,  May,  1909. 

'^Wien.  klin.  Wochen.,  May  16,  1912,  xxv,  20. 


28  BLOOD-PRESSURE 

toxins,  and  those  of  intestinal  origin,  have  a  most  pro- 
found effect  upon  the  blood-pressure  level  (see  page  255). 

3.  Glandular  Secretions. — The  chromaffin  system  has  of 
late  offered  a  fruitful  field  for  experimental  research  in 
many  directions,  among  which  the  relations  of  the  glands 
of  internal  secretion  to  both  normal  and  abnormal  blood- 
pressure  have  been  exhaustively  studied.^  In  spite  of 
this  experimental  activity  much  remains  to  be  done  and 
many  points  need  additional  light  before  the  complete 
relationship  of  the  several  glands  comprising  this  system, 
to  changes  in  the  circulation,  will  be  satisfactorily 
explained. 

The  adrenals,  the  pituitary,  and  the  thyroid  have  been 
shown  to  occupy  the  most  important  roles.  Early  ex- 
perimental work  in  this  direction,  notably  that  of  Hoskins, 
McClure,  and  Janeway  and  Park  was  unconclusive,  chiefly 
because  so  little  was  then  known  of  these  organs  and 
their  chemico-vital  effects,  that  the  premises  upon  which 
the  investigations  were  based  were  erroneous. 

The  clinical  effects  of  the  commercially  prepared  extracts 
of  the  thyroid,  the  pituitary  and  the  adrenals  on  the 
circulation  are  well  known  (see  pages  246-428)  yet  we  are 
by  no  means  assured  that  the  action  of  these  glands 
under  normal  conditions  of  secretion  is  the  same  either  in 
character  or  degree. 

The  pituitary  has  been  shown  experimentally^  to  have 

^  Fawcctt,  Rodgers,  Rahe  and  Beebe  (Am.  Jour.  Physiol.,  January,  1915, 
xxxvi,  No,  2);  Blackford  and  Landford  {N.  Y.  Med.  Jour.,  Sept.  13,  1913); 
Jordan  and  Eyster  {Am.  Jour.  Physiol.,  1911,  xxix,  p.  115);  Lewis,  Miller 
and  Matthews  {Arch.  Int.  Med.,  June,  1911,  p.  785);  Glay  and  Cleret  {Jour, 
de  Physiol,  el  de  Path.  Generale,  1911,  xiii,  p.  928). 

*  Behrenroth,  Deut.  Arch.  f.  hlin.  Med.,  cxiii,  Nos.  3  and  4. 


PHYSIOLOGY  29 

a  decidedly  mixed  action,  since  the  vasodilator  or  vaso- 
constrictor activity  of  the  extract  depends  upon  the 
portion  of  the  gland  employed. 

As  to  the  effect  of  the  normal  adrenal  secretion,  Hoskins 
and  McPeek^  have  failed  to  show  that  massage  of  the 
normal  adrenals,  in  narcotized  dogs  caused  a  rise  in  blood- 
pressure  at  all  comparable  to  that  following  the  ordinary 
employment  of  adrenalin  in  the  usual  doses.  And  they 
conclude  that  the  adrenal  secretion  is  not  an  immediate 
factor  in  normal  blood-pressure  maintenance. 

On  the  other  hand  in  high  blood-pressure  (from  abnormal 
adrenal  conditions)  C.  Quadrone^  treated  a  number  of 
cases  of  permanent  high  blood-pressure  by  exposing  the 
adrenals  to  the  X-ray  and  obtained  a  uniform  reduction 
of  the  systolic  pressure,  thus  confirming  the  experience  of 
Zimmern. 

It  is  also  shown  that  the  administration  of  thyroid  does 
not  invariably  cause  a  reduction  in  blood-pressure  even  in 
cases  where  there  is  a  marked  elevation. 

The  recent  work  of  Cannon  and  Nice^  demonstrated 
an  increased  adrenal  output  and  consequent  increase  in 
blood-pressure  in  cats  as  result  of  excitement. 

In  this  connection  H.  E.  Waller*  advances  the  plausible 
theory  of  the  interrelation  of  the  thyroid  and  adrenal 
secretions,  holding  that  he  has  proven  by  experimental 
work  that  such  an  interaction  really  exists  and  the  normal 

iR.  G.  Hoskins  and  C.  McPeek,  Jour.  A.  M.  A.,  June  7,  1913,  Vol.  LX, 
No.  23. 

^Rijorma  Medica,  Feb.  8,  1913,  xxix,  No.  6. 
^  Amer.  Jour.  Physiol.,  1913,  xxxii,  44. 

*  Practitioner,  London,  May,  1913. 


30  BLOOD-PRESSURE 

level  of  blood-pressure  is  maintained  through  the  channels 
of  secretion  by  varying  amounts  of  the  active  substances 
of  these  two  glands.  He  explains  the  blood-pressure  varia- 
tion in  myxedema  and  early  Graves  disease  upon  this 
basis.  That  these  substances  are  alone  in  control  of  the 
field  is  very  doubtful,  as  recently  Voegtlin  and  Macht^ 
claim  to  have  discovered  a  new  vasoconstrictor  substance 
from  the  blood  of  the  adrenal  cortex,  whose  physiologic 
action  is  somewhat  similar  to  that  of  digitalis,  while 
chemically  it  is  akin  to  lipoid  cholesterin. 

While  these  several  theories  may  be  in  part  reconciled 
to  our  present  knowledge  of  the  relations  of  blood-pressure 
in  health  and  disease,  they  must  not  be  accepted  as  con- 
clusively proven.  For  we  have  no  proof  that  the  sub- 
stances extracted  from  these  glands  ever  normally  enter 
the  blood-stream  in  a  chemical  form  that  we  are  able  to 
isolate  them. 

4.  The  Vasomotor  Nervous  Mechanism  Controlling 
Blood-pressure. — The  Maintenance  of  Tonus. — The  con- 
dition of  tonus  may  be  defined  as,  a  state  of  semicontrac- 
tion  of  the  several  coats  of  the  arterial  walls,  which  is 
maintained  through  the  activity  of  a  complicated  vasomotor 
mechanism.  This  condition  of  tonus  is  most  important, 
since  changes  in  the  force  and  frequency  in  the  heart's 
action,  and  variations  in  the  total  amount  of  blood  in  the 
body,  or  in  the  supply  to  any  organ  or  part,  would  be  at 
the  mercy  of  every  other  part,  unless  controlled  by  the 
automatic  contraction  and  dilatation  of  the  vessels  in 
other  parts  of  the  body.  Such  a  mechanism  is  essential 
to  the  proper  distribution  of  blood  to  all  regions  at  all 

^Carl  Voegtlin  and  David  I.  Macht,  Jour.  A.  M.  A.,  December  13,  1913. 


PHYSIOLOGY  31 

times.  This  condition  in  any  individual  part  is  known  as 
local  vascular  tone,  and  is  under  the  control  of  a  system  of 
nerve  ganglia  with  subservient  fibers,  which  are  found  in 
the  middle  coat  of  all  arteries.  The  energy  expended  by 
these  ganglia  is  manifested  by  a  constant  moderate  con- 
traction of  the  circular  muscular  coat  of  the  artery — a 
contraction  which  is  constantly  opposed  by  the  dilating 
force  (lateral  blood-pressure)  within  the  vessel.  An  exact 
equipoise  between  these  two  forces  never  occurs,  since 
each  factor  varies  constantly;  but  in  a  state  of  health, 
neither  one  ever  becomes  permanently  excessive.  Con- 
siderable variations,  however,  in  the  local  vascular  tone  are 
frequently  observed.  Thus,  each  organ  is  influenced  to  a 
certain  degree  by  every  other,  since  an  increase  in  blood 
in  one  part  must  necessarily  involve  a  decrease  in  other 
parts,  the  total  amount  of  blood  in  the  vessels  remaining 
constant.  Those  of  the  splanchnic  area  are  chiefly  con- 
cerned in  maintaining  this  balance,  since,  if  local  vasomotor 
control  of  these  regions  were,  for  any  reason,  abohshed, 
the  arteries  and  arterioles  would  dilate  sufficiently  to 
contain  practically  all  the  blood  in  the  body.  The  result 
would  be  a  condition  similar  to  that  following  a  massive 
hemorrhage. 

Alterations  in  the  heart's  action  are  felt  more  quickly 
in  some  organs  than  in  others  and,  thus  the  general  blood- 
pressure  for  cardiac  reasons  may  be  varied  sufficiently  to 
cause  secondary  disturbances  in  local  vascular  tone.^ 

The  nervous  mechanism  which  controls  local  vascular  tone 
is  a  complex  one,  consisting  not  only  of  a  set  of  local 
ganglia  in  relation  to  the  vessels  and  connected  with  the 

^  C.  J.  Wiggers,  Jour.  Exp.  Med.,  January,  1914,  xix,  p.  1. 


32  BLOOD-PRESSURE 

larger  sympathetic  ganglia;  but  also  of  centers  in  the 
spinal  cord,  which  are  in  turn  connected  with  higher 
centers  in  the  brain.  The  brain  centers  in  turn  are  com- 
plex, consisting  of  an  automatic  mechanism  in  the  medulla, 
regulating  the  action  of  all  the  subordinate  parts  below  it, 
and  of  a  series  of  cortical  centers  whose  function  it  is  to 
stimulate  or  inhibit  the  medullary  mechanism.^ 

Vasoconstrictors. — These  facts  seem  to  warrant  the  con- 
clusion that  the  energy  expended  by  the  local  ganglia  in 
holding  the  vessels  in  a  state  of  constant  moderate  con- 
traction, is  derived  from  the  central  nervous  system, 
primarily  from  the  automatic  center  in  the  medulla,  which 
in  turn  is  reinforced  by  each  of  the  secondary  centers  in 
the  spinal  cord  and  sympathetic  ganglia;  and  also  that, 
while  the  medullary  centers  control  the  entire  body,  the 
cord  and  sympathetic  centers  control  only  these  parts 
with  which  they  are  especially  related.  Any  injury  or 
interruption  in  the  impulse  to  one  or  more  of  these  parts 
will  produce  a  vascular  dilation  through  interference  with 
the  transmission  of  vasoconstrictor  impulses  from  within 
outward;  and  irritation  of  one  or  more  of  these  parts  may 
cause  a  contraction  of  the  vessels  by  increasing  the  normal 
stimulus  sent  out  to  local  ganglia  by  the  vasoconstrictors. 
An  example  of  the  general  action  of  such  irritation  is 
shown  by  the  increasing  pressure  in  cerebral  hemorrhage 
or  intracranial  pressure  variation  due  to  abscess  or  tumor, 
and  locally,  in  the  vascular  condition  met  in  true  migraine 
(Starr). 

1  M.  Allan  Starr,  Jour.  A.  M.  A.,  Vol.  liii,  No.  3,  July  17,  1909,  from  whose 
article  much  of  the  material  relating  to  vasomotor  influence  has  been 
taken. 


PHYSIOLOGY  33 

Vasodilators. — The  action  thus  far  considered  has  been 
wholly  of  the  vasoconstrictor  kind,  and  the  dilatation 
mentioned  has  been  due  to  a  cessation  or  reduction  of  the 
constrictor  energy  normally  passing  outward.  This  may 
be  termed  a  passive  dilatation.  It  is  the  kind  produced 
by  division  of  any  one  of  the  sympathetic  ganglia. 

Experiments  have  shown,  however,  that  another  kind 
of  dilatation  can  be  produced,  traceable  not  to  a  mere 
cessation  of  constrictor  impulses,  but  to  an  impulse  of  a 
positive  nature  sent  out  to  local  ganglia  and  resulting  in  a 
sudden  suspension  of  their  activity.  Such  an  impulse  is 
really  inhibitory,  arresting  the  action  of  the  ganglia  in 
spite  of  the  continued  stimuli  sent  to  them  from  the 
central  nervous  system.  The  result  is  a  dilatation  of 
the  arteries,  produced  by  the  blood-pressure  within; 
this  may  be  termed  an  active  dilatation.  An  important 
difference  has  been  established  between  these  two  sets  of 
impulses,  namely,  that  while  the  action  of  the  former  is 
constant,  that  of  the  latter  is  intermittent.  Therefore 
they  cannot  be  regarded  as  opponents  of  each  other. 

From  the  anatomic  standpoint  the  vasodilators  can  be 
traced  upward  in  a  manner  similar  to  those  controlling 
the  vasoconstrictors,  and  experimental  research  has  dem- 
onstrated the  exact  course  of  these  fibers  in  relation  to 
the  various  parts  of  the  central  nervous  system,  it  has 
also  been  demonstrated  that  they  exist  as  separate  nerves, 
sometimes  running  together,  although  they  usually  enter 
the  spinal  cord  at  different  levels. 

Vasomotor  Reflexes. — Vasomotor  reflexes  are  found  in  all 
parts  of  the  body,  examples  of  which  are  seen  in  the  effect 
of  a  change  of  temperature,  or  of  pain,  upon  local  or  general 


34  BLOOD-PBESSURE 

blood-pressure,  or  in  the  color  of  the  face  and  the  size  of 
the  pupil.  It  is  probable  that  the  major  vasomotor 
reflexes  are  of  a  chemical  nature,  the  chemical  substance 
often  acting  directly  upon  the  lining  of  blood-vessels  so 
that  this  subject  is  closely  related  to  the  two  preceding, 
namely,  the  chemical  and  glandular  activities  (see  page  26). 

Having  reviewed  our  present  knowledge  of  the  phy- 
siologic relations  of  blood-pressure  and  vasomotor  tone, 
we  can  now  approach  the  practical  clinical  side  of  this 
subject  more  intelligently  as,  through  this  knowledge  we 
are  more  readily  able  to  comprehend  the  complex  changes 
occurring  in  blood-pressure  in  disease. 

For  practical  purposes  it  will  be  found  convenient  to 
consider  the  maintenance  of  normal  blood-pressure  and 
the  production  of  abnormal  pressures,  more  from  the 
clinical  standpoint,  while  admitting  them  to  be  dependent 
upon  these  primary  physiologic  divisions.  This  is  at 
least  the  most  convenient  because  more  capable  of  clinical 
demonstration  and  study. 

From  a  clinical  standpoint  the  factors  concerned  in  the 
maintenance  of  circulatory  equilibrium  are: 

First. — The  energy  of  the  heart. 

Second. — Peripheral  resistance. 

Third. — Arterial  tonus. 

Fourth. — Volume  of  the  blood. 

Fifth. — Viscosity. 

They  appear  to  be  related  to  the  physiologic  factors  in 
the  following  manner: 

The  energy  of  the  heart,  to  the  mechanical  arrangement, 
and  to  the  nervous  mechanism;  peripheral  resistance  and 
arterial  tonus  to  the  chemical  changes,  glandular  secre- 


PHYSIOLOGY  35 

tions  and  the  nervous  mechanism.  The  volume  of  the 
blood  to  the  chemical  changes  and  nervous  mechanism  and 
the  viscosity  of'  the  chemical  composition. 

One  should  not  be  led,  in  the  consideration  of  this 
subject  into  the  belief  that  these  several  factors  are  entirely 
separable.  As  a  matter  of  fact  they  are  all  so  interrelated 
that  it  is  utterly  impossible  to  decide  where  the  effect 
of  one  ceases  and  that  of  another  begins;  since  the  normal 
circulation  is  made  up  of  the  sum  of  activities  and  of 
these  factors,  which  all  may  and  which  do  vary  con- 
stantly, under  both  normal,  and  in  pathologic  conditions. 
While  it  might  be  theoretically  possible  for  one  factor 
alone  to  produce  discernible  alterations  in  the  circulation, 
it  is  improbable  that  it  ever  does,  as  all  are  so  closely 
related  one  to  the  other  any  definite  alteration  in  one  of 
them  must  result  in  change  in  others.  We  are,  therefore, 
forced  to  a  consideration  of  the  subject  as  a  whole,  while 
acknowledging  and  endeavoring  to  isolate  the  predominat- 
ing effect  of  one  or  more,  in  relation  to  the  pathologic 
changes  found  in  any  given  case. 


CHAPTER  II 

TERMS  AND  DEFINITIONS  EMPLOYED  IN  THE 
STUDY  OF  ARTERIAL  PRESSURE 

Before  undertaking  a  study  of  the  clinical  relations  of 
blood-pressure,  with  its  many  and  complex  variations  of 
both  physiologic  and  pathologic  origin,  it  is  essential  to 
have  a  knowledge  of  the  different  terms  now  in  common 
use  in  the  study  of  blood-pressure,  to  be  familiar  with  the 
several  accepted  methods  of  study  and  to  have  a  practical 
conception  of  the  relations  of  the  several  events  in  the 
cardiac  cycle  to  the  various  factors  concerned  in  the 
maintenance  of  normal  arterial  pressure.  A  brief  review 
of  these  matters  may  be  conveniently  considered  here. 

BLOOD-PRESSURE 

Beginning  with  a  broad  general  significance,  when  the 
term  blood-pressure  was  applied  to  almost  any  condition 
of  arterial  pressure  in  any  part  of  the  circulatory  system. 
The  word  has  gradually  become  restricted,  so  that  at  the 
present  writing,  unless  qualified  by  defining  adjectives,  the 
term  has  become  so  indefinite,  that  it  should  not  be  em- 
ployed. The  term,  to  have  any  clinical  significance,  must 
be  qualified  by  the  proper  adjective,  which  will  indicate 
what  particular  part  of  this  general  subject  is  under 
consideration,  thus:  systoUc  blood-pressure;  diastolic  blood- 
pressure;  pulse  pressure;  mean  pressure;  average  pressure; 

36 


STUDY    OF   ARTERIAL   PRESSURE  37 

venous  pressure;  capillary  pressure;  intraventricular  pres- 
sure, etc. 

Definition. — When  unqualified,  the  term  blood-pressure 
is  taken  to  mean  the  systolic  blood-pressure  as  measured 
in  the  brachial  artery,  though  it  is  advisable  to  be  more 
specific  in  all  discussions  and  writings  upon  the  subject 
of  pressures,  and  to  apply  carefully  the  proper  qualifying 
words  in  order  to  afford  more  definite  scientific  and  there- 
fore more  accurate  information. 

In  the  chapter  on  physiology  it  has  been  said  that 
arterial  pressure  is  subject  to  many  and  various  modifying 
factors  and  that  we  know  now  that  the  arterial  pressure 
is  in  a  state  of  constant  rhythmic  fluctuation  due  to  the 
intermittency  of  the  cardiac  systoles,  and  also  that  the 
arterial  pressure  in  normal  individuals  at  all  times  is 
dependent  upon  the  proper  correlation  of  five  distinct  and 
separately  determinable  factors  (see  page  34). 

Our  present  nomenclature  of  arterial  pressure  includes  a 
number  of  terms  some  of  which  will  be  briefly  defined  and 
discussed. 

First. — Arterial  pressure  (either  end  or  lateral)  which  is 
divided  into: 

Second. — (a)  Systolic  or  maximal  pressure  (measured 
by  end  pressure)  and 

Third. — (6)  Diastolic  or  minimal  pressure  (measured  as 
lateral  pressure)  from  which  we  determine. 

Fourth. — The  pulse  pressure,  range  or  amplitude. 

Fifth. — Mean  arterial  pressure. 

Sixth. — Average  arterial  pressure. 

The  Arterial  Pressure. — This  is  found  to  differ  according 
to  the  manner  of  its  measurement;  thus  the  pressure  which 


38  BLOOD-PRESSURE 

is  exerted  against  the  vessel  wall  while  the  current  of  blood 
is  flowing  unopposed  by  direct  obstruction,  is  known  as  the 
lateral  pressure;  whereas  the  pressure  exerted  by  the  blood 
against  any  obstruction  which  reduces  the  lumen  of  the 
vessel  is  known  as  the  end  pressure.  The  latter  exceeds 
the  former  when  measured  at  any  given  point  in  the 
arterial  tree  and  the  difference  between  the  two  is  the 
measure  of  the  dynamic  power  of  the  heart  which  is 
involved  in  actually  carrying  on  blood  flow  at  this 
point. 

In  clinical  sphygmomanometry,  the  methods  employed 
yield  the  end  systolic  pressure  and  the  lateral  diastolic 
pressure,  and  it  is  these  pressures  that  are  to  be  inferred 
when  encountered  in  blood-pressure  discussion. 

The  Systolic  or  Maximal  Pressure. — This  term  indicates 
the  maximum  force  exerted  by  the  systole  of  the  heart. 
It  is  the  transmitted  intraventricular  pressure.  This 
pressure  measured  in  the  brachial  artery  while  it  is  less 
than,  nevertheless  tends  to  approximate,  the  intracardiac 
pressure,  and  the  lateral  pressure  in  the  aorta.  ^  Thus 
when  we  say  that  the  systolic  pressure  is  equal  to  125 
mm.  Hg.,  we  mean  that  the  end  pressure  in  the  artery  at 
the  point  of  obstruction  by  the  sphygmomanometer  cuff, 
is  capable  of  sustaining  a  column  of  mercury  of  125  mm. 
over  and  above  the  atmospheric  pressure. 

The  Absolute  Pressure. — To  determine  the  absolute 
systolic  pressure,  it  is  necessary  to  add  to  the  observed 
systolic  pressure  in  mm.  Hg.,  the  actual  barometric  pressure 
as  measured  by  the  same  scale,  at  the  time  of  estimation. 
This   point  should   not  be  forgotten,   although   such   an 

1  Louis  M.  Warfield,  Int.  Med.  Jour.,  xix,  No.  10,  October,  1912. 


STUDY    OF   ARTERIAL   PRESSURE  39 

estimation  is  rarely  employed  except  in  physiologic  and 
experimental  investigations. 

Accuracy  of  the  Systolic  Pressure  Estimation. — The  dif- 
ference between  the  systolic  pressure,  determined  by 
sphygmomanometry  in  the  brachial  artery,  as  compared 
with  that  found  in  the  aorta  by  direct  measurement 
in  animals  is  so  slight  that,  for  practical  purposes,  it  is 
ignored.  Therefore,  when  the  systolic  pressure  is  as- 
certained in  the  brachial  artery,  it  represents  a  satisfactory 
clinical  measure  of  the  pressure  throughout  the  arterial 
system  except  in  very  small  vessels. 

The  systolic  blood-pressure  may  be  divided  into  two 
distinct  portions,  which  have  a  valuable  clinical  and  patho- 
logic significance  of  the  measure  of  the  force  exerted  by 
the  heart.  It  is  compounded  of  the  pressure  required  to 
overcome  the  minimal  pressure  in  the  aorta  (the  meas- 
ure of  peripheral  resistance)  plus  the  force  necessary  to 
cause  arterial  flow  and  to  sustain  the  circulation  in  normal 
equilibrium  (heart  work). 

Diastolic  or  Minimal  Arterial  Pressure. — This  term 
refers  to  the  pressure  found  in  the  smaller  arterials  and 
transmitted  backward  to  the  general  arterial  tree.  It  is, 
therefore,  the  measure  of  peripheral  resistance  and  repre- 
sents the  amount  of  pressure  that  the  left  ventricle  must 
exert  before  it  can  reestablish  the  forward  movement 
of  blood  in  the  arterial  system. 

As  the  blood  goes  farther  and  farther  from  the  heart 
toward  the  smaller  arterials  situated  on  the  confines  of 
the  arterial  tree,  the  systolic  and  diastolic  pressures  tend 
to  approximate  each  other,  until  when  the  capillaries  are 
reached  the  rhythmic  fluctuation  is  lost,  and  a  uniform 


40 


BLOOD-PRESSURE 


flow  of  blood  issues  from  the  capillaries  (see  page  25). 
Thus  being  dependent  upon  a  fairly  constant  factor  (per- 
ipheral resistance),  the  diastolic  pressure  varies  very  little 
in  the  larger  arteries,  where  it  is  a  comparatively  fixed 
factor  as  compared  with  the  systolic  pressure. 

All  other  factors  remaining  unchanged,  a  high  peripheral 
resistance  means  a  high  diastolic  pressure  and  a  low 
peripheral  resistance  means  a  low  diastolic  pressure.  In 
other  words,  vasoconstriction  raises  and  vasodilatation 
lowers  diastolic  pressure. 

The  Pulse  Pressure,  Range  or  Amplitude. — These  syn- 
onymous terms  are  employed  to  designate  the  blood-pres- 
sure variation  in  the  arterial  tree,  occurring  at  any  given 
point  during  a  cardiac  cycle.  It  represents  the  actual 
head  of  pressure  driving  the  blood  toward  the  periphery 
and  is  the  measure  of  the  force  exerted  by  the  ventricle 


SystoUc=130 

Range='46    ] 
DiastoIic=  85 


Mean=107 


Fig.  2. — Normal    pulse    tracing:   showing   relation    of   systolic,    diastolic, 
pulse  pressure  and  mean.     Pulse  pressure  equals  45. 

over  and  above  that  required  to  overcome  peripheral  re- 
sistance (diastolic  pressure).  It  becomes  evident,  there- 
fore, that  the  pulse  pressure  may  at  any  time  be  determined 
by  subtracting  the  diastolic  pressure  from  the  systolic  pres- 
sure and  that  without  these  observations  the  pulse  pressure 
cannot  be  ascertained  (see  Fig.  2). 

The  determination  of  the  pulse  pressure  is  of  great  im- 
portance in  clinical  medicine,  particularly  in  the  prognosis 


STUDY    OF    ARTERIAL    PRESSURE  41 

of  many  cardiovascular  diseases,  as  it  in  all  probability 
indicates  alterations  in  heart-muscle  efficiency  not  only  in 
cardiac  disease  itself,  but  also  in  acute  and  chronic  in- 
fections, cachectic  states,  etc.  It  is  also  used  clinically 
to  determine  the  actual  velocity  of  blood  flow. 

The  Mean  Pressure. — There  seems  to  be  a  degree  of 
confusion  and  uncertainty  in  the  minds  of  physicians  and 
students  regarding  the  terms  mean  and  average  as  applied 
to  blood-pressure  findings.  These  terms  are  frequently 
employed  synonymously,  although  as  far  as  I  have  been 
able  to  ascertain  they  should  not  be  used  interchangeably 
even  when  coincidently  they  may  be  found  to  be  the 
same.  I  would  emphasize  this  because,  in  a  number  of 
recent  articles  and  in  at  least  one  recent  text-book  these 
terms  have  been  loosely  employed.  Thus  ''by  mean 
pressure  is  understood  the  average  pressure  (italics  mine) 
at  a  given  point;  the  mean  pressure  is  not,  however,  the 
arithmetical  mean  between  the  systolic  and  diastolic 
pressure,  because  the  pressure  may  rise  for  only  a  moment 
to  the  systolic  level,  falling  very  gradually  to  near  the 
diastolic  level  and  remaining  near  it  throughout  the  greater 
part  of  the  average  cycle.  "^ 

Whatever  the  accepted  usage  of  terms,  average  and 
mean  may  come  to  be,  it  is  plain  that  they  are  used  so 
ambiguously  that  they  interfere  with  a  proper  under- 
standing of  a  definite  nomenclature. 

Strictly  speaking,  we  may  obtain  an  average  only  by 
adding  the  sum  of  any  number  of  similar  units  and  dividing 
this  sum  by  the  number  of  units  in  the  series,  while  we  can 
obtain  a  mean  only  as  between,  two  similar  units.     We 

1  Norris,  1914  edition. 


42 


BLOOD-PRESSURE 


cannot  therefore,  determine  the  mean  between  the  systolic 
and  the  diastolic  pressure  unless  it  be  of  two  isolated 
observations,  any  more  than  plums  could  represent  the 


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FiQ.  3. — Woley's  chart  showing  effect  of  age  on  blood-pressure,   giving 
mean,  high  and  low  average. 


mean  between  peaches  and  pears  (see  average  pressure 
figures  in  Woley's  table.  Fig.  3).  The  only  possible  way 
of  obtaining  the  mean  pressure,  either  systolic  or  diastolic, 
in  a  series  of  observations,  as  for  example  to  determine 


STUDY    OF    ARTERIAL    PRESSURE  43 

the  mean  systolic  and  the  mean  diastolic  pressure  for  a 
given  age,  would  be  to  pair  all  the  observations  of  the 
systolic  pressure,  making  each  pair  the  extremes,  after 
having  eliminated  at  each  calculation  the  most  widely 
separated  pair.  The  result  of  the  means  obtained  in  this 
way  would  be  a  series  of  figures  approximating  each 
other,  but  not  necessarily  identical.  This  series  of  figures 
could  then  be  added  and  an  average  mean  obtained,  which 
would  in  no  way  except  by  accident  resemble  the  average. 
The  same  process  carried  out  upon  the  diastolic  pressure 
observations  would  produce  an  average  mean  diastolic 
pressure  and  from  these  a  general  mean  pressure  might,  if 
advisable,  be  determined,  and  such  a  figure  would  not, 
except  accidentally,  be  similar  to  half  the  pulse  pressure 
added  to  the  diastolic  of  any  observation  in  the  series. 

The  Average  Pressure. — In  sphygmomanometry,  we 
depend  on  the  average  pressure  either  systolic,  diastolic 
or  pulse  pressure  as  the  most  practical  way  of  estimating 
the  limits  of  normal  variation.  This  will  be  referred  to 
in  the  chapter  upon  normal  pressures  and  their  variation 
(see  page  112). 

The  value  and  clinical  significance  of  the  mean  pressure 
is  yet  to  be  determined. 

THE  CAUSES  OF  ARTERIAL  PRESSURE  AND  THE  FACTORS  IN- 
VOLVED   IN    ITS    MAINTENANCE 

We  beheve  the  arterial  pressure  to  be  dependent  upon  five 
separate,  distinct  and  individually  variable  factors. 

These  several  factors  are  found  to  vary  continually 
under  normal  conditions  while  in  pathologic  states  they  may 
and  do  undergo  great  and  permanent  changes,  which  are 


44  BLOOD-PRESSUBE 

reflected,  as  either  transient  or  permanent  variations  in 
blood-pressure. 

Arterial  blood-pressure  at  any  given  time  is  the  sum  of 
these  factors  plus  their  reciprocal  relations. 

Not  only  may  one  vary  independently  of  the  other,  but 
they  are  capable  also  of  most  complicated  interaction. 

1.  The  Heart  Energy. — The  heart  is  a  force  pump  of 
intermittent  action  and  is  the  most  important  factor  in  the 
circulation  as  it  is  the  fountain  head  of  all  energy.  But 
of  itself  it  is  powerless  to  maintain  the  circulation  without 
the  supplementary  and  supporting  factors  above  men- 
tioned. Thus  while  the  heart  supplies  the  force  which 
causes  the  flow  of  blood,  it  is  the  peripheral  resistance 
and  arterial  elasticity  which  are  chiefly  concerned  with 
the  maintenance  of  an  adequate  blood-pressure  during 
the  diastolic  pause,  while  the  heart  is  resting,  which 
aggregates  according  to  Brunton^  on  the  average  in  the 
normal  circulation,  thirteen  hours  out  of  the  twenty-four. 

The  left  ventricle  during  systole  forces  the  column  of 
the  blood  into  the  arterial  system  while  during  diastole  the 
blood  is  distributed  forward  throughout  the  arterial  tree. 

Any  increase  in  the  rapidity  in  the  discharge  of  blood 
from  the  heart  (increase  in  volume  output  per  minute) 
will,  the  other  factors  remaining  constant,  cause  a  rise  in 
systolic  blood-pressure.  Conversely  any  diminution  in  the 
pulse  rate  or  volume  output  will  cause  a  reduction  in  systolic 
blood-pressure.  On  the  other  hand  a  compensatory  rela- 
tion between  the  heart  rate  and  the  volume  output  may 
permit  either  or  both  (if  inversely)  to  be  altered  without 
any  appreciable  change  in  blood-pressure. 

1  Lauder  Brunton,  Brit.  Med.  Jour.,  Nov.  5,  1910. 


STUDY    OF    ARTERIAL    PRESSURE  45 

2.  Peripheral  Resistance. — Peripheral  resistance  is  that 
factor,  ever  present  in  the  circulatory  system,  which 
tends  to  retard  and  prevent  the  forward  movement  of  the 
circulating  blood.  In  the  human  body  this  is  a  com- 
plicated factor,  being  dependent  in  part  upon  (a)  the 
diminishing  diameters  of  the  conducting  tubes,  particularly 
in  the  arterioles  and  capillaries,  (6)  internal  friction,  (c) 
the  length  of  the  vessels  and  (d)  the  innumerable  branching 
of  the  arterial  tree. 

It  is  obvious  that  any  obstruction,  even  if  partial,  at 
the  outlet  of  any  distensible  tube  will  increase  the  lateral 
pressure  exerted  by  the  fluid  in  that  tube.  A  familiar 
example  of  this  is  the  effect  of  the  adjustable  nozzle  used 
on  the  garden  hose.  The  same  physical  law  holds  good 
for  the  arterial  system,  except  that  the  intermittency  of 
flow  is  a  complicating  factor,  which  includes  the  inter- 
relation of  two  variables — the  systolic  and  the  diastolic 
pressures.  The  result  of  these  factors  is  to  produce  a 
condition  in  which  increased  peripheral  resistance  (in- 
creased vasomotor  tone)  will  increase  systolic  pressure 
while  a  diminished  peripheral  resistance  will  lower  both 
systolic  and  diastolic  pressure.  This  change  invariably 
occurs  unless  some  compensating  factor  modifies  the 
force  of  the  heart  (energy  index,  page  140). 

The  other  factors,  including  length  of  tube  and  internal 
friction,  being  practically  constant  may  be  safely  omitted 
in  clinical  considerations,  without  introducing  any  serious 
element  of  error  (for  further  discussion  of  peripheral  re- 
sistance and  vasomotor  tone,  see  Chapter  VII,  page  138). 

Elasticity  and  Contractility  of  the  Vessel  Wall. — The 
elasticity  and   contractility  of  the  blood-vessel   walls  is 


46  BLOOD-PRESSURE 

dependent  upon  the  circular  muscular  coat  and  the  elastic 
lamina.  Were  it  not  for  this  quality  of  the  arteries,  the 
heart  would  be  called  upon  to  do  a  great  deal  of  unnecessary- 
work  which  would  absorb  a  vast  amount  of  valuable 
energy,  while  the  flow  of  blood  throughout  the  arterial 
system  would  be  intermittent,  as  the  heart  at  each  beat 
would  be  required,  in  order  to  complete  its  systole,  to 
drive  the  whole  volume  of  blood  forward  and  through 
the  capillaries — a  condition  obviously  incompatible  with 
normal  physiology  in  the  body. 

Thus  during  each  systole  the  heart  muscle  performs  work 
in  maintaining  arterial  flow  against  peripheral  resistance. 
A  large  part  of  this  work,  which  is  sudden  and  explosive 
(at  systole),  is  compensated  for  by  the  expansion  of  the 
arterial  walls. 

A  part  of  the  manifest  energy  of  the  heart  thus  becomes 
for  a  time  potential  in  the  stretched  fibers  of  the  arterial 
wall.  The  moment  that  a  systole  is  at  an  end,  the  stretched 
fibers  recoil  and  continue  the  work  of  the  heart  in  main- 
taining the  arterial  flow  against  peripheral  resistance. 

As  this  potential  energy  becomes  expended  the  systolic 
pressure  gradually  falls  and  would  eventually  reach  zero 
were  it  not  for  peripheral  resistance  plus  the  rhythmically 
recurring  cardiac  systole  which  causes  the  pressure  to 
rise  again. 

The  laminal  elasticity  of  the  vessels  is  very  perfect  and 
is  capable  of  standing  a  pressure  greater  than  by  any 
chance  could  possibly  be  developed  during  life.  According 
to  Janeway,^  quoting  Gr^hant  and  Quinguard,  the  carotid 
artery  of  a  dog  is  capable  of  withstanding  a  pressure, 

^  Loc.    cit.,    p.    24. 


STUDY    OF    ARTERIAL    PRESSURE  47 

twenty  times  greater  than  the  normal  blood-pressure 
without  tearing.  For  the  human  carotid  the  lowest 
pressure  at  which  rupture  occurs  is  1.29  meters  of  mercury, 
at  least  eight  times  the  ordinary  carotid  pressure  of  the 
normal  circulating  blood. 

4.  Total  Volume  of  the  Blood. — Compared  with  the 
capacity  of  the  arteries,  capillaries  and  veins  combined,  the 
total  volume  of  blood  is  surprisingly  small,  being  variously 
estimated  to  be  from  one-twelfth  to  one-fifteenth  of  the 
body  weight.  In  the  normal  individual  the  cubic  capacity 
of  the  vascular  system  is  so  reduced  by  vasomotor  control 
(see  page  30)  that  the  blood  at  all  times  is  maintained 
under  a  considerable  pressure. 

While  a  certain  amount  of  blood,  probably  about  three- 
fourths  that  of  the  normal  volume,  is  necessary  to  support 
the  circulation,  still  it  has  been  found  that  a  large  amount  of 
blood  can  be  withdrawn  without  interrupting  cardiac 
action  (see  Venesection,  page  460)  and  further  that  the 
pressure  rapidly  returns  to  a  point  at  or  near  normal 
soon  after  the  cessation  of  the  hemorrhage.  On  the 
other  hand,  Worm  Miiller  has  shown  that  an  amount 
of  fluid  greater  than  the  total  blood  volume  of  the  body 
can  be  transfused  into  the  vessels,  without  increasing  the 
blood-pressure  above  a  point  frequently  reached  under 
normal  conditions.  Therefore,  it  would  seem  that,  except 
for  great  changes,  the  volume  of  the  circulating  blood 
has  only  a  slight  and  temporary  influence  on  normal 
blood-pressure. 

5.  The  Viscosity  of  the  Blood. — This  factor  has  until 
recently  been  almost  entirely  ignored  in  observations  and 
discussions  of  the   normal   and  pathologic  variations  in 


48  BLOOD-PRESSURE 

blood-pressure.  It  is,  however,  evidently  a  most  im- 
portant factor  in  determining  peripheral  resistance.  This 
has  been  brought  out  by  Allbutt^  who  states  'Hhat  it  is 
evident  that  friction  in  the  arterial  tree  must  multiply 
with  every  increase  in  viscosity  as  it  has  been  demonstrated 
that  nearly  200  times  more  of  the  heart's  energy  is  ex- 
pended in  overcoming  friction  than  is  required  in  main- 
taining the  velocity  of  the  blood-stream."  Variation  in  this 
factor,  even  when  slight,  must  affect  enormously  the  re- 
sistance offered  to  the  passage  of  blood  through  the  arterial 
system  and  therefore  must  profoundly  affect  the  blood- 
pressure,  so  that  we  should  follow  most  carefully  any  varia- 
tion however  small,  in  the  viscosity  of  the  circulating 
fluid. 

Determann  has  found  in  plethoric  persons,  with  high 
blood-pressure  an  increase  in  viscosity,  while  A.  Martinet 
has  shown  that  in  normal  cardiovascular  conditions  the 
blood-pressure  parallels  the  viscosity.  It  will  probably  be 
found,  as  experimentation  is  carried  further,  that  the 
viscosity  of  the  blood  is  a  most  important  factor  in  affecting 
blood-pressure,  and  that  the  development  of  methods 
for  its  modification  or  control  will  mark  an  epoch  in  the 
study  and  treatment  of  diseases  involving  blood-pressure 
changes. 

When  the  viscosity  is  normal  or  below,  as  in  renal 
arteriosclerosis  for  example,  the  blood-pressure  will  be  high. 
On  the  other  hand,  if  the  viscosity  is  high,  while  the 
blood-pressure  is  normal  or  below,  the  pulse  will  be  weak. 
Martinet  has  endeavored  to  build  up  a  chnical  picture  upon 
this  basis,  in  which  such  symptoms  as  cold  hands  and 

1  Clifford   Allbutt,  Quarterly  Jour.  Med.,    1910,   p.   242. 


STUDY    OF   ARTERIAL   PRESSURE  49 

feet,  congestion  of  the  liver,  varices  and  various  cardio- 
vascular disturbances  predominate. 

The  Pulse. — From  our  knowledge  of  the  action  of  the 
heart,  we  know  that  blood  is  forced  into  the  aorta  at  regular 
intervals,  and  that  each  charge  of  blood  entering  the  aorta 
is  felt  throughout  the  arterial  system  in  the  form  of  a 
wave  which  is  styled  the  pulse  and  which  may  be  felt 
as  a  rhythmically  recurring  impulse  (due  to  transitory 
increase  in  size  of  the  vessel)  in  all  palpable  arteries. 

The  propagation  of  this  wave  throughout  the  arterial 
system  implies  a  change  in  diameter  of  the  vessel  \\'ith 
a  resulting  stretching  of  the  vessel  wall  (see  Elasticity, 
page  45)  caused  by  the  increased  increment  of  blood 
entering  it.  This  further  stretching  of  an  already  stretched 
vessel  wall  can  occur  only  through  an  increase  in  pressiue 
within  the  vessel  sufficient  to  cause  the  increased  diameter  of 
the  vessel  which  is  left  under  the  finger.  It  is  a  self-evi- 
dent fact,  then  that  there  occurs  alternately,  in  regular 
rhythmic  cycle,  a  rise  and  fall  in  blood-pressure  throughout 
the  arterial  system.  Corresponding  to  the  ventricular 
systole  and  diastole,  the  highest  and  lowest  point  of  this 
change  in  pressure  are  termed  respectively,  systolic 
blood-pressure  and  diastolic  blood-pressure  (See  Fig.  2). 

4 


CHAPTER  III 
THE  PRINCIPLE  OF  THE  SPHYGMOMANOMETER 
THE  INSTRUMENTAL  ESTIMATION  OF  BLOOD-PRESSURE 

The  basis  of  modern  sphygmomanometry  is  founded 
upon  circular  pneumatic  compression,  without  which  the 
modern  sphygmomanometer  could  not  have  been  developed, 
and  the  immense  value  of  the  results  of  blood-pressure 
study  might  still  be  unknown  to  clinical  medicine. 

The  direct  method  of  the  physiologist  is  not  applicable, 
as  it  would  require  a  direct  communication  between  the 
blood-vessel  and  the  tube  leading  to  the  manometer,  and 
is  therefore  not  practical  for  the  consulting  room  even  if 
tolerated  by  the  patient. 

Circular  Compression. — It  remained  for  Riva-Rocci^ 
and  Hill  and  Barnard^  each  working  independently  of 
the  other,  to  substitute  the  arm-encircling  cuff  for 
the  uncertain  and  inaccurate  pelote  of  the  early  investi- 
gators. 

By  means  of  the  encircling  arm-band  (either  full  or 
partial)  the  pressure  produced  within  the  hollow  inflatable 
rubber  portion  is  exerted  equally  from  every  direction 
against  the  artery.  Physiologic  experiment  has  shown 
this  method  to  be  accurate,  as  the  tissues  intervening 
between  the  arm-band  and  the  artery  offer  a  negligible 

^Gazz.  Med.  di  Torino,   1896,  Nos.  50  and  51. 

2  Leoziard  Hill  and  H.  Barnard,  Brit.  Med.  Jour.,  1897,  Vol.  2,  p.  904. 

50 


THE    PRINCIPLE    OF   THE    SPHYGMOMANOMETER 


51 


resistance,^  so  that  the  readings  obtained,  indirectly 
through  the  tissues,  by  the  modern  method,  agree  very 
closely  with  those  obtained  by  the  direct  method. 

Character  of  Cuff. — It  has  already  been  said  that  the 
width  of  the  tubular  cuff  influences  to  a  significant  degree 
the  readings  obtained.  Janeway  has  found  in  high-pressure 
cases  that  there  exists  a  difference  of  as  much  as  60  mm. 
between  the  12-cm.  and  the  5-cm.  arm-band.  ^     This  is 


=0 


<?- 


C-r 


Fig.  4. — A.  Schematic  section  of  arm,  showing  narrow  arm-band  (a) 
with  retaining  device,  (6)  before  inflation  artery  (c).  B.  Same,  showing 
change  in  form  of  compression  band  (a),  after  inflation,  artery  (c)  com- 
pressed. Note  great  change  in  form  and  increase  in  circumference  of 
compression  bag.  This  change  occurred  only  at  the  expense  of  a  measurable 
amount  of  pressure. 


easily  explained  by  noting  the  change  which  occurs  within  a 
narrow  (2  in.)  and  a  wide  (4)^  in.)  cuff  during  inflation  under 
a  rigid  retaining  device — reference  to  the  accompanying 
illustration  will  aid  the  explanation.  Fig.  4  shows  a 
narrow  armlet  which  allows  insufficient  material  to  indent 


1  Von  Recklinghausen,  Arch.  f.  Exp.  Pathol,  u.  Pharmakol.,  1901,  xlvi, 
78;  Gumprecht,  Zeitsch.  f.  klin.  Med.,  1900,  xxxv;  and  Hensen,  Deutsch, 
Arch.  f.  klin.  Med.,  1900,  xlvii,  p.  4. 

^  T.  C.  Janeway,  "Clinical  Study  of  Blood-pressure,"  1907,  D.  Appleton 
&.  Co. 


52 


BLOOD-PRESSURE 


the  tissues  and  compress  the  vessel  without  requiring 
additional  pressure  to  expand  the  rubber  bag,  this  amount 
being  registered  on  the  scale  of  the  sphygmomanometer  in 
addition  to  that  required  to  compress  the  vessel.  Cham- 
berlain^ has  determined  that  this  amount  of  error  on  an  arm 
of  average  size  is  8  mm.  or  more. 

Fig.  5  shows  wide  arm-band  (A)  before  compression 
and  (B)  after  compression,  where  the  change  in  form  of 
the  rubber  portion  is  insufl&cient  to  exert  pressure  beside 
that  required  to  indent  the  tissues  and  compress  the  vessel. 


Fig.  5. — A.  Schematic  section  of  arm  showing  wide  arm-band  (a)  with 
retaining  device  (b)  and  artery  (c)  before  inflation.  B.  Same,  showing 
change  in  form  of  compression  bag  (a)  after  inflation  artery  (c)  compressed, 
note  slight  change  in  form  of  compression  bag,  insufficient  to  exert  any 
additional  force  than  that  required  to  compress  artery. 


Influence  of  the  Vessel  Wall. — Upon  this  subject 
authorities  differ.  The  early  experiments  of  v.  Basch^ 
show  that  the  resistance  of  a  normal  radial  artery  to 
closure  scarcely  amounts  to  1  mm. 

RusselP  takes  the  opposite  stand  when  he  says,  '^I 
cannot  but  think  that  those  who  have  thought  that  the 

^  Chamberlain,  Philippine  Jour,  of  Set.,  vi.  Sec.  B,  December,  1911. 
*  Berlin,  klin.  Wochen.,  xxiv,  1887. 

'  Wm.  Russell,  "Arterial  Hypertension,  Arteriosclerosis  and  Blood-pres- 
sure," J.  B.  Lippincott  Co.,  1908,  p.  52. 


THE   PRINCIPLE    OF   THE    SPHYGMOMANOMETER  53 

arterial  wall  is  negligible,  have  not  had  the  data  necessary 
to  a  correct  opinion." 

Hoover^  recently  attempted  to  prove  Russell's  contention 
by  submerging  an  arm  or  leg  in  an  ice-filled  trough  and 
demonstrating  the  changes  in  arterial  pressure  caused 
thereby.  In  this  work  Hoover  apparently  failed  to 
recognize  the  well-known  effect  of  peripheral  constriction 
upon  the  proximal  portion  of  the  vessel  (i.e.,  central  to 
the  constriction)  which,  in  his  experiments  is  undoubtedly 
the  cause  of  the  rise  in  pressure;  it  therefore  cannot  be 
ascribed  to  change  in  the  condition  of  the  arterial  wall. 

Jane  way  2  and  later  Jane  way  and  Park^  believe  the 
element  of  error  to  be  greater  than  was  formerly  supposed, 
as  they  found  that  the  resistance  offered  by  the  arterial 
wall  in  adults  with  normal  pressures  to  be  more  than  1  or 
2  mm.  Hg.  while  they  were  able  to  demonstrate  that  this 
rarely  equalled  more  than  10  mm.  Hg.  Practically  this 
difference  may  be  discounted  as  in  adults  the  factor  is  a 
comparatively  fixed  one,  and  being  ever  present  may  be 
clinically  ignored,  and  also  because  it  is  no  more  than 
the  spontaneous  variation  occurring  in  any  individual  from 
time  to  time  (often  within  a  few  minutes).  In  children  the 
factor  is  entirely  negligible. 

Arteriosclerosis,  according  to  Jane  way  and  Park,^  even 
when  marked,  increases  but  moderately  the  normal  re- 
sistance to  compression.  By  actual  experiment  they 
found  that  it  did  not  exceed  17  mm.  Hg. 

1  C.  F.  Hoover,  Jour.  A.  M.  A.,  Vol.  Iv.  No.  10,  Sept.  3,  1910. 

*  "Clinical  Study  of  Blood-pressure,"  1st  edition,  1907,  p.  61. 
»  Arch.  Int.  Med.,  No.  6,  1910. 

*  hoc.  cil. 


54  BLOOD-PRESSURE 

From  the  data  at  hand,  we  may  conclude  that  the  vessel 
wall,  as  a  factor,  need  not  be  considered  from  a  clinical 
standpoint,  as  any  resistance  which  could  be  offered  by  a 
vessel  even  markedly  sclerosed,  would  be  insignificant  when 
compared  to  the  alterations  in  pressure  often  occurring 
within  the  vessel  in  disease.  I  submit  as  further  proof 
the  many  high-pressure  cases  met  here  but  little  change  can 
be  demonstrated  in  the  superficial  vessels,  while  on  the 
other  hand,  cases  occur  whose  superficial  vessels,  as  far 
as  they  can  be  digitally  traced,  are  absolutely  rigid  and 
yet  blood-pressure  by  palpation  may  never  register  over 
110  mm. 

Influence  of  Other  Intervening  Structures. — Vital  tissue 
is  perfectly  elastic;  therefore  any  pressure  applied  to  the 
surface  of  a  living  body  will  be  transmitted  directly  to  the 
underlying  structure  without  loss  of  force. 

It  would  seem,  therefore,  safe  to  assume  that  both  the 
vessel  wall  and  the  intervening  tissues,  as  definite  factors 
which  modify  blood-pressure  readings,  can  be  absolutely 
eliminated,  at  least  clinically,  because  all  pressures  are 
read  through  them  and  so,  as  they  are  always  included  in 
the  estimation,  they  can  be  ignored. 

THE  ESTIMATION  OF  BLOOD-PRESSURE 

No  one  will  deny  at  this  time  the  great  importance  of 
accurate  blood-pressure  estimation,  and  the  signal  value 
that  clinical  medicine  has  derived  from  the  modern  sphyg- 
momanometer. Neither  will  anyone  be  deluded  into  be- 
lieving that  he  or  anyone  else  is  able,  by  tactile  sense  alone, 
to  determine  the  relative  height  of  blood-pressure  with 
anything  like  the  same  degree  of  accuracy  as  is  attained 


THE    PRINCIPLE    OF   THE    SPHYGMOMANOMETER  55 

by  the  modern  sphygmomanometer.  While  it  may  be 
true  that  extremes  in  pressure  might  be  recognized,  it  is 
also  true  that  the  smaller  variations,  which  are  after  all 
often  the  most  important  clinically,  cannot  be  detected 
with  any  degree  of  certainty,  if  at  all. 

We  will  consider  therefore,  that  no  further  argument  is 
necessary,  but  will  assume  it  to  be  an  accepted  fact  that 
the  accurate  estimation  of  arterial  tension  is  to  be  ac- 
complished only  by  means  of  sphygmomanometry. 

With  the  older  instruments  it  was  possible  to  roughly 
estimate  the  systolic  pressure.  At  the  present  time 
approximate  estimations  are  no  longer  sufficient  as  we  now 
believe  it  essential  to  determine  with  accuracy  not  only 
the  systolic  pressure  but  also  the  diastolic  and  pulse 
pressures,  as  well.  Experience  has  taught  us  that  while 
the  systolic  pressure  is  important,  it  is  nevertheless  only  a 
part,  and  frequently  but  a  small  part  of  the  information 
sought. 

It,  therefore,  becomes  extremely  important  to  consider 
clinically  the  accepted  methods  of  sphygmomanometry 
and  to  possess  a  working  knowledge  of  the  methods  and 
instruments  employed. 

There  are  a  large  number  of  instruments,  mostly  of  very 
recent  devising,  which  may  be  relied  upon  in  competent 
hands  for  this  estimation,  and  the  choice  between  them  is 
largely  a  personal  matter.  So  that  in  the  pages  to  follow 
all  statements  referring  to  specific  instruments  are  in- 
tended only  to  supply  a  certain  amount  of  working  knowl- 
edge, obtained  through  actual  experience,  which  may 
save  the  reader  unnecessary  experimentation  when  selecting 
an  instrument. 


56  BLOOD-PRESSURE 

METHOD  OF  EMPLOYING  THE  MODERN  SPHYGMOMANOMETER 

Having  already  considered  the  subject  of  blood-pressure 
in  the  abstract  and  having  reviewed  the  critera  surrounding 
the  proper  performance  of  the  study,  we  are  now  in  a 
position  to  consider  the  actual  clinical  employment  of  the 
sphygmomanometer. 

All  modern  clincial  instruments  are  operated  in  con- 
junction with  the  elastic  cuff  or  arm-band,  which  after 
encircling  one  of  the  extremities  is  inflated,  so  that  by 
compression  it  will  obliterate  the  arterial  pulse.  The 
measure  of  air  pressure  at  the  moment  of  complete  ob- 
struction is  the  measure  of  the  systolic  pressure.  This 
has  already  been  shown  on  page  50  to  approximate  the 
actual  arterial  pressure,  as  determined  simultaneously  by 
the  direct  introduction  of  a  canula,  so  closely  that  the 
difference  (a  few  mm.  Hg)  may  be  ignored.  These  read- 
ings if  made  with  any  modern  type  of  instrument  are 
comparable,  as  they  all  give  the  pressure  readings  in  terms 
of  millimeters  of  mercury.  The  several  forms  of  apparatus 
will  be  discussed  in  detail  later.  Except  for  the  style 
and  construction  of  the  manometer  there  is  very  little 
difference  in  the  several  apparatus  either  as  regards  their 
modus  operandi  or  their  clinical  use,  the  only  differences 
being  slight  variations  in  minor  details  such  as  the  material 
forming  arm-band,  the  location  of  tubes  and  other  attach- 
ments, etc. 

SUGGESTIONS   TO    BE   FOLLOWED    AND   PRECAUTIONS   TO   BE 
OBSERVED  WHILE  USING  THE  SPHYGMOMANOMETER 

Position  of  the  Patient. — Whether  the  observation  is 
made  in  the  reclining  or  sitting  posture  will  be  determined 


THE    PRINCIPLE    OF   THE    SPHYGMOMANOMETER  57 

by  the  nature  of  the  case  and  by  exigencies  of  practice. 
In  the  critically  ill  the  horizontal  posture  is  preferable, 
although  it  will  not  always  be  found  convenient  or  possible 
in  the  presence  of  orthopnea,  while  in  ambulatory  cases 
it  will  not  always  be  found  convenient  to  employ  the 
horizontal.  One  point  to  be  borne  in  mind  is  that  for 
purposes  of  comparison  it  is  essential,  whenever  possible, 
to  make  all  subsequent  observations  in  a  case  in  the  same 
posture  as  was  the  first.  At  all  events  the  location  of 
the  arm-band,  irrespective  of  the  patient's  posture,  should 
be  at  the  heart-level,  thus  eliminating  the  error  due  to 
gravity.  Under  all  circumstances  the  patient  should  be 
in  a  comfortable  position,  and  one  favoring  muscular 
relaxation. 

Application  of  Cuff. — The  cuff  is  usually  apphed  to  the 
arm,  above  the  elbow  and  should  be  maintained  at  the 
heart-level,  Fig.  6.  It  should  be  applied  directly  to  the 
bared  arm  or  over  very  thin  coverings  and  wrapped  firmly; 
this  will  avoid  the  unnecessary  delay  required  to  fully 
inflate  a  loosely  applied  arm-band.  The  arm-band  should 
not  exert  pressure.  This  point  is  also  of  importance  in 
using  any  method  other  than  the  auscultatory,  since  the 
greater  the  volume  of  confined  air  the  less  marked  will  be 
the  rhj'thmic  impulse  transmitted  to  the  manometer. 

Time  of  Observation. — T\Tienever  possible  'observations 
should  be  made  at  about  the  same  time  of  day,  and  in  the 
same  relation  to  the  taking  of  food.  Observations  should 
not  be  made  during  periods  of  excitement,  or  after  exercise, 
or  in  periods  of  profound  fatigue,  neither  after  the  ingestion 
of  large  amounts  of  fluid  or  of  stimulants,  as  tea,  coffee 
or  alcohol.     An  overheated  or  unduly  chilled  extremity 


58 


BLOOD-PRESSURE 


will  affect  the  arterial  pressure  in  the  part  (see  page  145). 
Observations  made  under  pathologic  conditions,  such  as 
edema  or  spasms,  are  absolutely  unreliable. 

Fear  and  psychic  disturbances  markedly  influence  the 
readings  (see  page  59);  for  this  reason,  in  the  nervous 
and  excitable,  the  initial  reading  is  often  higher  than 
those  made  subsequently. 


Fig.   tj. — Auscviltatory  blood-pressure  test. 


Condition  of  Indicator  and  Cuff. — A  leaky  apparatus 
will  give  unreliable  readings;  old  rubber  parts  are  often 
responsible  for  this.  When  properly  connected  the  ap- 
paratus should  be  able  to  sustain  the  mercury  column  with- 
out receding.  A  rapid  fall  indicates  a  leak  somewhere  in 
the  air  system  and  should  be  corrected.  At  the  beginning 
of  each  test  the  indicator,  irrespective  of  type,  should 
register  zero  and  in  the  mercury  instruments  the  mercury 


THE   PRINCIPLE    OF   THE    SPHYGMOMANOMETER  59 

column  should  not  be  broken.  This  latter  condition 
may  be  overcome  by  abruptly  jarring  the  apparatus  until 
the  mercury  unites. 

The  Performance  of  the  Test. — The  greatest  rapidity 
compatible  with  accuracy  is  essential,  since  undue  delay 
while  the  arm  is  under  compression  will,  through  vasomotor 
influences,  give  a  disagreeable  sensation,  and  may  also 
affect  the  systolic  pressure.  Two  or  more  readings  should 
be  made  whenever  possible  for  purposes  of  verification  and 
to  eliminate  psychic  and  other  transitory  sources  of 
variation,  and  no  single  observation  should  be  accepted 
when  it  is  possible  to  make  additional  ones. 

No. 
BLOOD-PRESSURE  RECORD 

Name Age Sex 

Diagnosis Date 

Systolic mm mm.... 

Diastolic m  m mm.... 

Pulse  Pressure mm mm.... 

Mean mm mm.... 

Pulse  Rate Reg.  Irreg.  Intermit 

Treatment 

Remarks 

Fig.  7. — Author's  index  card. 

The  Keeping  of  Records. — Whenever  possible  blood- 
pressure  records  should  be  preserved,  this  not  only  makes 
for  accuracy  in  individual  readings  but  also  furnishes 
valuable  data  for  comparison,  not  only  in  the  same  case, 
but  also  in  statistical  studies. 

For  this  purpose  the  author  has  for  some  time  employed 
a  small  card  upon  which  individual  daily  records  are  made 
and  filed  (see  Fig.  7)  and  from  which,  when  desired, 
graphic  charts,  similar  to  those  shown  throughout  this 
work,  are  easily  compiled. 


60  BLOOD-PRESSURE 

Imparting  Information  to  the  Patient. — Except  in  rare 
instances  the  patient  should  not  be  given  specific  in- 
formation regarding  his  blood-pressure,  as  it  is  extremely 
easy  for  certain  individuals  to  become  so  imbued  with  the 
importance  or  omnipotence  of  this  observation,  that 
they  develop  a  distinct  neurasthenic  stripe.  There  are, 
however,  certain  types  of  cases  in  which  much  good  will 
follow  a  frank  discussion  of  this  subject  with  the  patient, 
as  for  example,  in  the  case  of  one  who  is  firmly  of  the 
opinion  that  the  height  of  his  blood-pressure  indicates 
a  grave  and  rapidly  fatal  condition  and  who  may  be  re- 
lieved permanently  of  this  anxiety  by  demonstrating  a 
physiologic  level  in  the  absence  of  such  a  condition.  The 
other  type  is  the  neurasthenic  who  has  inordinate  reliance 
in  this  test  and  who  if  he  can  be  shown  a  distinct  im- 
provement in  pressure  during  the  physician's  conduct  of 
his  case,  will  naturally  be  helped  to  a  recovery. 

The  Personal  Equation  of  the  Examiner. — Fortunately, 
for  clinical  medicine  this  factor  is  largely  eliminated  by  the 
auscultatory  method  and  now  really  exists  only  in  deter- 
mining the  diastolic  point  according  to  the  present  in- 
terpretation of  the  sound  phases  (see  Chapter  V,  page 
90). 

In  the  tactile  method  there  is  often  an  element  of  error 
of  from  5  to  10  mm.  between  different  observers.  This 
may  be  due  either  to  lack  of  experience  and  hence  un- 
trained tactile  acuity,  or  to  subjective  pulsations  felt  by 
the  observer.  The  frequency  with  which  this  subjective 
pulse  becomes  evident  cannot  be  determined,  but  if  sus- 
pected it  can  easily  be  eliminated  by  a  simultaneous  obser- 
vation of  the  pulse  of  both  the  operator  and  the  patient. 


THE    PRINCIPLE    OF   THE    SPHYGMOMANOMETER  61 

In  my  experience  with  students  employing  the  ausculta- 
tory method  there  is  rarely  any  appreciable  element  of 
error  after  the  students  have  once  learned  to  appreciate  the 
significance  of  the  sounds. 

By  tactile  sense  the  determination  of  the  diastolic 
pressure  cannot  be  relied  upon  except  when  determined  by 
those  of  constant  and  wide  experience.  Another  source 
of  error  will  depend  upon  whether  the  readings  are  made 
as  the  pressure  in  the  instrument  is  ascending  or  descend- 
ing (see  page  141).  It  will  be  found  here  that,  owing  often 
to  slight  obstruction  to  the  free  passage  of  air  in  the 
apparatus,  the  pressure  in  the  manometer  will  not  im- 
mediately respond  to  the  changes  of  pressure  in  the  cuff. 
Another  element  of  error  may  arise  from  the  fact  that, 
when  using  a  pump  or  bellows,  the  rising  pressure  is  not 
as  easily  controlled  as  the  descending.  Therefore,  except 
under  special  conditions,  all  observations  should  be  made 
after  first  rapidly  and  completely  obliterating  the  pulse. 
There  is  one  exception  to  this  which  has  recently  been 
called  to  my  attention  by  Dr.  Francis  J.  Dever,  namely, 
in  aortic  regurgitation.  Here  in  determining  the  diastolic 
pressure  during  the  release  the  change  from  the  third  to 
the  fourth  phase  may  be  so  slight  that  it  is  missed,  whereas 
with  a  rising  pressure,  after  the  diastolic  pressure  has  been 
approximately  determined,  it  will  be  found  that  the  pas- 
sage from  the  fourth  to  the  third  phase  will  be  very  sharp 
and  distinct. 


CHAPTER  IV 

THE  SPHYGMOMANOMETER 

METHOD  OF  ITS  USE  AND  DESCRIPTION  OF  INSTRUMENTS 

The  use  of  manometers  or  upright  tubes  filled  with  fluid, 
in  the  study  and  measurement  of  blood-pressure  in  man  is 
attributed  to  an  English  clergyman,  Stephen  Hales,  ^  who 
published  the  results  of  his  experiments  in  1733,  but  it 
was  not  until  recently  that  a  systematic  study  of  the 
circulation  as  shown  by  the  blood-pressure  was  undertaken. 

With  our  increasing  knowledge  of  the  circulatory 
mechanism,  both  in  health  and  disease,  it  has  become 
increasingly  essential  to  have  instruments  of  precision  which 
will  enable  physicians  to  study  circulatory  phenomena, 
estimate  circulatory  efficiency  and  measure  the  work  of  the 
heart. 

With  the  earlier  instruments  and  the  former  methods 
only  the  systolic  pressure  could  be  gauged;  but  this  is  no 
longer  sufficient,  as  the  systolic  pressure  by  itself  may  fail 
to  give  the  information  required.  Both  the  systolic  and 
the  diastolic  readings  are  now  determined  and  in  addition 
we  have  also  learned  to  depend  much  upon  other  collateral 
data,  coincidentally  acquired  with  modern  instruments 
and  improved  methods. 

A  great  variety  of  apparatus  for  the  estimation  of 
human  blood-pressure  has  been  devised,  the  development 
and    application    of   which   having   now   become    almost 

*  Stephen  Hales,  "Statistical  Essays,"  London,  1733,  Vol.  ii. 

62 


THE    SPHYGMOMANOMETER  63 

"ancient  history,"  they  will  be  just  touched  upon  here. 
In  many  of  these  older  instruments  either  the  principal  or 
the  technique  or  both  were  at  fault;  hence  consideration 
need  be  given  only  to  a  few  of  the  representative  modern 
instruments  of  the  last  few  years.  These  are  great  im- 
provements over  the  previous  ones,  and  have  demonstrated 
their  ability  to  give  dependable  and  accurate  blood-pressure 
values. 

DEVELOPMENT  OF  THE  SPHYGMOMANOMETER 

Graphic  methods  for  determining  blood-pressure  in  man 
began  with  Vierordt  in  1855  who  attempted  to  measure 
blood-pressure  by  placing  weights  on  the  radial  artery 
until  the  pulse  was  obliterated. 

The  first  practical  instrument,  however,  was  introduced 
by  Marey  in  1876,  but  his  work  seems  to  have  been  prac- 
tically forgotten  until  von  Basch,  in  1887  devised  an 
instrument  which  at  that  time  found  some  favor.  This 
instrument  recorded  only  the  systoUc  pressure,  and  is 
important  chiefly  because  it  was  the  direct  forerunner  of 
all  modern  instruments.  The  instrument  of  von  Basch 
employed  intermediate  compression — a  rubber  bulb  filled 
with  water  and  communicating  by  a  tube  with  a  mercury 
manometer,  by  which  the  radial  artery  was  compressed. 
The  systolic  pressure  was  determined  by  measuring  the 
amount  of  pressure  necessary  to  obliterate  the  lumen  of 
the  artery  and  obstruct  the  pulse,  which  was  indicated  by 
the  mercury  column.  In  a  later  model  von  Basch  sub- 
stituted a  spring  manometer  for  the  mercury  column. 
In  1889  Potain  replaced  the  water  of  the  earlier  instruments 
with  air,  and  modified  the  pressure  in  the  circuit  at  will 


64  BLOOD-PRESSURE 

by  means  of  a  bulb,  connected  with  the  apparatus  by  a 
branch  tube.  He  also  improved  his  apparatus  by  using 
the  chamber  of  an  aneroid  barometer  for  measuring 
pressure. 

In  1896  Riva-Rocci^  and  Hill^  published  almost  simul- 
taneously articles  descriptive  of  new  sphygmomanometers. 
The  important  feature  of  each  of  these  instruments  was 
the  introduction  of  a  rubber  bag  or  tube  encircling  the 
arm  and  inflated  by  a  bulb  or  a  pump.^  This  improve- 
ment surmounted  the  most  serious  defect  in  the  earlier 
instruments,  which  was  the  difficulty  of  accurately  adapting 
the  small  round  pelote  to  the  arm,  thereby  compressing 
the  artery  (the  radial)  directly  over  the  bone.  By  the 
method  of  Riva-Rocci  and  Hill,  the  pressure  is  everywhere 
exerted  at  right  angles  to  the  tangent  of  the  circumference 
of  the  arm,  and  the  artery  therefore  compressed  equally 
from  three  sides  against  the  bone  (see  page  66,  Fig.  8). 

Since  this  time  there  has  been  practically  no  change 
in  the  principles  of  sphygmomanometry.  Improvements 
have  tended  toward  perfecting  the  apparatus  and 
simplifying  the  technique,  changes  having  been  directed 
chiefly  toward  portability,  in  means  of  circular  compres- 
sion and  source  of  pressure,  and  the  style  of  the  manometer. 

From  the  narrow  arm-band  as  originally  employed  by 
Riva-Rocci  (4.5  cm. — 2  in.)  to  the  extremely  wide  band  of 
von  Recklinghausen,  numerous  investigators  have  de- 
termined that  a  cuff  11  to  13  cm.   (4>^-5  in.)  in   width 

1  Gaz.  Med.  di  Torino,  1896,  Nos.  50  and  51. 

2  Bnl.  Med.  Jour.,  1897,  Vol.  ii,  p.  904. 

2  For  the  accuracy  of  this  method  as  compared  with  the  direct  or  camilar 
method,  see  page  39. 


THE    SPHYGMOMANOMETER  65 

gives  the  most  accurate  readings,  with  the  possible  ex- 
ception of  the  extremely  obese.  A  special  narrow  cuff 
may  also  be  found  advantageous  in  work  with  very  young 
children,  manufactured  at  my  suggestion  by  the  G.  P. 
Pilling  and  Son  Company,  Philadelphia,  Pa. 

Technique  and  Employment  of  the  Sphygmomanometer. 
— From  the  practical  clinical  standpoint  all  modern 
sphygmomanometers  are  applied  and  measure  blood- 
pressure  in  the  same  manner.  Therefore,  a  general  de- 
scription will  explain  the  manner  of  application  of  all. 
For  convenience  of  description  the  modern  sphygmoman- 
ometer may  be  divided  into  the  following  parts: 

1.  The  source  of  air  pressure. 

2.  The  compression  device. 

3.  The  manometer  or  indicator. 

1.  The  source  of  air  pressure  may  be  a  compressed  air 
supply  similar  to  that  employed  to  operate  atomizers,  a 
rubber  bulb,  or  a  small  metal  force  pump.  The  function 
of  this  portion  of  the  instrument  is  merely  to  inflate  the 
compression  member  and  by  so  doing  to  exert  a  variable 
degree  of  pressure  upon  the  artery  under  examination. 
The  source  of  pressure  is  joined  by  suitable  tubular  means 
to  the  compression  member. 

2.  The  compression  member  is  composed  of  a  hollow 
elastic  air-containing  portion  and  a  rigid,  leather  or  fabric- 
retaining  portion.  These  are  so  arranged  that  when 
applied  to  an  extremity,  the  hollow  elastic  portion  is  in 
contact  with  the  skin  surface  of  the  arm  or  leg,  which 
it  encircles  either  partially  or  completely.  Outside  this 
the  restraining  portion  is  fastened,  in  a  suitable  manner, 


66 


BLOOD-PRESSURE 


to  restrain  the  elastic  portion  and  to  force  the  pressure 
inward  against  the  member  and  so  through  it  to  the 
artery. 

Fig.  8,  A  and  B,  shows  the  relation  of  the  compression 
bag  to  the  artery.     In  Fig.  A,  the  pressure  within  the  cuff 


Fig.  8. — Diagram  of  relations  of  armlet  to  brachial  artery.  A.  Pressure 
in  "b"  135  mm.  Hg.,  pressure  in  "a"  130  mm.  Hg.,  B  is  therefore  collapsed, 
pulse  cannot  pass.  B.  Pressure  "b"  129  mm.  Hg.,  pressure  in  "a"  130mm. 
Hg.,  pulse  passes.  Explanation  of  systolic  reading:  a,  arterj^;  b,  compress- 
ing armlet;  c,  retaining  cuff;  d,  tube  to  manometer;  e,  humerus. 

is  greater  than  the  blood-pressure  within  the  artery,  which 
is  therefore  collapsed  and  the  pulse  in  the  distal  end  of 
the  vessel  cut  off.  In  Fig.  B,  the  pressure  in  the  cuff  has 
been  reduced  so  that  it  is  a  fraction  of  a  millimeter  less 
than   the   systolic   pressure   within   the   vessel.     Now   at 


THE   SPHYGMOMANOMETER 


67 


each  systole,  a  small  amount  of  blood  will  pass  beyond  the 
constriction  and  will  reach  the  distal  end  of  the  artery, 
where  the  wave  can  be  felt  by  the  palpating  finger  at  the 
wrist. 

Fig.    9,    A    and    B,  represents  the    conditions    existing 


Fig.  9. — A.  Systolic  pressure  in  "a"  130  mm.  Hg.,  pressure  in  "6"  101 
mm.  Hg.,  artery  not  compressed.  B.  Diastolic  pressure  in  "a"  100  mm, 
Hg.,  pressure  in  "b"  101  mm.  Hg.,  artery  collapsed.  Diagram  of  relation 
of  armlet  to  brachial  artery.  Explanation  of  diastolic  reading;  a,  artery; 
h,  compressing  armlet;  c,  retaining  cuff;  d,  tube  to  manometer;  e,  humerus. 

between  the  constricting  cuff  and  the  vessel  at  the  diastolic 
time  of  pressure.  A  represents  a  pressure  within  the  cuff 
less  than  the  systolic  pressure  in  the  vessel.  This  is 
insufficient  to  affect  the  vessel  during  the  systolic  period, 
while  B  shows  the  artery  and  cuff  during  the  diastolic 


68  BLOOD-PRESSURE 

period,  at  the  moment  when  the  pressure  within  the 
artery  is  at  its  lowest  point,  a  fraction  of  a  milHmeter  less 
than  the  pressure  within  the  cuff.  Consequently  the 
artery  is  collapsed  at  this  time.  The  effect  of  each  suc- 
ceeding systole  is  to  alternate  between  a  round  and  a  flat 
vessel  at  the  point  of  compression.  This  affects  the 
pressure  of  air  within  the  cuff  which  is  in  turn  transmitted 
to  the  mercury  column  of  the  manometer  and  becomes 
visible  in  the  rhythmic  fluctuation  of  the  column  of  mercury 
which  is  synchronous  with  the  pulse  beat. 

3.  The  indicator,  manometer  or  gauge,  is  a  device  for 
measuring  the  amount  of  air  pressure  exerted  against  the 
artery.  The  modern  types  give  the  measure  of  pressure 
in  terms  of  millimeter  Hg.,  rendering  the  readings  of  all 
instruments  comparable.  The  indicator  is  the  part  of 
the  modern  sphygmomanometer,  which  has  had  focussed 
upon  its  construction  the  greatest  inventive  skill  and 
ingenuity.  Many  medical  men  of  mechanical  ability  have 
made  slight  changes  in  minor  or  superficial  details;  as  in 
shape  and  size  of  the  manometer  tube,  or  in  the  location  of 
attachments  for  tubular  connections  in  the  mercury  in- 
struments, and  in  the  form  of  the  containing  case  in  the 
aneroids.  Hence  we  find  a  multiplicity  of  names  attached 
to  many  slightly  varying  instruments. 

Blood-pressure  instruments  are  usually  classified  accord- 
ing to  the  style  and  type  of  measuring  device  employed. 
These  may  be  grouped  as  follows: 

CLASSIFICATION    OF   BLOOD-PRESSURE    INSTRUMENTS 

Modified  from  G.  W.  Norris,  "Blood-pressure,  its 
Clinical  Applications,"  Lea  and  Febiger,  1914. 


THE    SPHYGMOMANOMETER  69 

I.  Mercury  manometers: 
1.  Reservoir,   Riva-Rocci,   Cooke,   Stanton,  Pilling- 
Special    and    Pilling-Midget,     Nicholson,     Hill, 
Kercher,  Hollman,  Gartner,  Westenrijk. 
2.  U-shaped:  Janeway,    Taught,    Martin,    Linnell, 
Fellner. 
11.  Compressed-air  manometers :  Oliver,  Benedick,  Herz. 

III.  Aneroid    manometers:  Rogers,    Brunton,    Faught, 
Pachon,  Jacquet. 

IV.  Spring  manometers:  von  Recklinghausen,  Stern. 

V.  Instruments  for  graphic  registration :  Erlanger,  Gib- 
son, Bingel,  Singer,  Uskoff,  Silbermann,  Brugsch, 
Stursberg,  Muenzer,  Strauss-Fleischer,  Bussenius, 
Wybauw 
VI.  Instruments  constructed  with,  or  to  which  may  be 
fitted,  special  oscillating  indices,  such  as  the  Fedde 
or  Pal  oscillometers,  Bing,  Faught,  Vaquez,  Widmer. 
Rodgers. 

DESCRIPTIONS  OF  MODERN  INSTRUMENTS 

1.  Riva-Rocci  Sphygmomanometer  (Fig.  10). — This  mer- 
cury manometer  is  of  cistern  form,  and  is  constructed  of 
heavy  glass  from  which  emerge  two  tubes,  one  for  the  in- 
flating apparatus  and  one  for  the  attachment  of  the  arm- 
band. The  latter  is  provided  with  a  release  valve  for 
gradually  lowering  the  pressure  in  the  circuit  during  the 
test.  The  scale  engraved  upon  the  glass  tube  reads  up 
to  260  mm.  Hg. 

The  armlet  consists  of  a  hollow  rubber  tube  covered 
with  silk  having  a  width  of  4.5  cm.  (2  in.),  which  is  fastened 


70 


BLOOD-PRESSURE 


to  the  arm  with  a  special  clamp.  The  inflating  apparatus 
is  a  double  bulb  such  as  is  employed  with  a  thermocautery. 

Advantages. — The  apparatus  stands  firmly  on  a  solid 
base  has  a  scale  easily  read,  it  is  adjusted  rapidly  and  is 
rapid  in  operation. 

Disadvantages. — The  armlet  is  too  narrow  for  accurate 
readings,  the  apparatus  is  too  fragile  and  totally  unavailable 
for  pressures  over  260  mm.  (10  in.)  of  mercury. 


Fig.   10. — Riva-Rocci's  sphygmomanometer.      (Sahli   and  Potter.) 


2.  Cook's  Modification  of  the  Riva-Rocci  (Fig.  11). — 
This  is  very  similar  to  the  preceding  but  is  of  lighter  con- 
struction, and  is  provided  with  a  jointed  manometer  tube 
which  allows  the  instrument  to  be  packed  in  a  smaller 
space.  It  employs  the  double  bulb  inflator,  and  gives 
readings  directly  in  millimeters  Hg.  which  are  read 
from  a  scale  etched  upon  the  glass. 

Disadvantages. — It  does  not  stand  firmly  being  easily 
upset  and  broken.     Without  special  care  in  packing  and 


THE    SPHYGMOMANOMETER 


71 


transportation  the  mercury  is  frequently  spilled.  The 
caliber  of  the  tube  (1  mm.)  is  too  small.  The  scale  etched 
upon  the  glass  is  difficult  to  read. 

3.  Stanton's  (Later  Called  Sands)  Sphygmomanometer 
(Fig.  12). — This  instrument  was  devised  in  an  effort  to 
increase  portability,  to  reduce  the  probability  of  breakage 


Fig.   11.— Cook's    modification    of    the    Riva-Rocci    sphygmomanometer, 
showing  narrow  arm-band  in  place,   with  cautery  bulb  inflator. 

and  to  lessen  the  elasticity  of  the  tubular  system,  thereby 
improving  the  diastoUc  fluctuation  of  the  mercury. 

These  changes  were  effected  by  substituting  a  metal 
cistern  and  by  arranging  over  this  a  screw  joint  for  the 
attachment  of  the  vertical  glass  tube;  also  by  the  intro- 
duction of  a  stopcock  in  the  short  tube  as  it  emerges  from 
the  cistern  to  serve  for  attachment  of  the  inflating  bulb. 


72 


BLOOD-PRESSURE 


This  eliminates  the  elasticity  of  the  inflating  apparatus 
during  the  diastolic  reading.  The  instrument  employs 
the  standard  12-cm.  (4i^-in.)  cuff,  retained  on  the  arm  by 
a  canvas  outer  cuff  and  buckle  straps. 

Disadvantages. — Chieflj'  the  time  and  skill  required  to 
set  up  the  apparatus  before  using,  and  the  great  difficulty 


Fig.   12. — Stanton's   sphygmomanometer,   showing   arrangement   of  parts 
with  cautery  bull)  inflator. 

in  avoiding  the  loss  of  mercury  during  the  setting-up 
process.  Also  the  cistern  arrangement  gives  low  readings 
in  high  pressures. 

4.  Janeway's  Sphygmomanometer  (Fig.  13). — In  the 
construction  of  the  Janeway  apparatus  we  see  a  return  to 
the  U-tube  type,  first  devised  by  von  Basch.  This  form 
appears  to  be  a  more  accurate  method  of  employing  the 


THE    SPHYGMOMANOMETER 


73 


mercury  column,  as  in  the  cistern  form  no  cognizance 
is  taken  of  the  change  in  the  level  of  the  mercury  in  the 
cistern,  which  must,  for  physical  reasons,  give  too  low 
readings  when  employed  in  the  study  of  high  pressures. 

This  instrument  employs  the  circular  compression  band 
of  standard  width  and  a  Politzer  bag  for  inflation.     In 


Fig.  13. — Janeway's  sphygmomanometer,  attached  to  arm,  showing 
method  of  retention  of  cuff,  arrangement  of  momanometer.  with  PoUtzer 
bag  inflator. 

addition  to  this  the  only  original  feature  of  this  instrument 
is  the  jointed  U-tube  which  allows  the  instrument,  with  the 
exception  of  the  cuff  and  inflating  bag,  to  be  contained  in  a 
case  measuring  103^^  X  4%  X  1%  in.  and  weighing  23>^ 
lb.  The  open  end  of  the  manometer  tube  is  closed  with  a 
cork  when  not  in  use,  and  the  rubber  connection  on  the 
other  limb  leading  to  the  attachments  is  compressed  by 


74 


BLOOD-PRESSURE 


closing  the  case,  to  prevent  loss  of  mercury  from  the 
manometer.  The  scale  is  arranged  to  slide  down  into  the 
box  when  not  in  use.  The  arm-band  is  12  cm.  (43-^  in.) 
wide  and  is  retained  on  the  arm  by  a  non-elastic  outer 
cuff  provided  with  friction  straps. 

Advantages. — This  apparatus  is  light,  compact  and  port- 
able and  the  readings  accurate. 


Fig.   14. — Faught's  nur(ur\'  sphygmomanometer,  showing  rehition  of  parts, 
metal  pump,  and  special  expansion  tubing  for  inflator. 

Disadvantages. — The  frailness  of  jointed  U-tube.  The 
mercury  is  easily  spilled  because  of  the  inadequate  method 
emploj'^ed  to  confine  it  when  the  instrument  is  not  in  use. 
The  rubber  connections  are  short-lived  and  must  often  be 
renewed. 

5.  The  Faught  Standard  Mercury  Sphygmomanometer 
(See  Fig.  14). — This  apparatus  was  devised  early  in  1909, 
in  an  endeavor  to  overcome  the  shortcomings  of  existing 


THE    SPHYGMOMANOMETER  75 

instruments,  the  majority  of  which  were  found  to  be  frail, 
besides  requiring  special  skill  to  operate,  consuming  too 
much   time   and   being   above  all  defective  mechanically. 

The  Standard  sphygmomanometer  is  of  the  U-tube  type 
and  all  complicated  parts  have  been  either  simplified  or 
eliminated.  The  complete  apparatus  including  the  cuff 
of  standard  width,  and  the  inflating  pump  may  be  enclosed 
in  a  mahogany  carrying  case,  measuring  14  X  4  X  43^^  in. 
The  lid  is  hinged  and  locks  in  a  vertical  position  to  serve 
as  the  support  of  the  manometer  and  the  connections. 
Each  arm  of  the  U-tube  is  provided  with  a  guard  cock  which 
remains  closed,  except  during  actual  use  of  the  instru- 
ment, thus  preventing  absolutely  any  loss  of  mercury, 
excepting  with  gross  carelessness.  There  are  no  rubber 
connections  to  wear  out.  The  upper  nipple  to  which  the 
pump  is  attached  is  provided  with  a  stopcock,  which  must 
be  closed  during  the  systolic  and  diastolic  readings.  The 
millimeter  scale,  which  can  be  adjusted  to  the  level  of  the 
mercury  is  reduced  one-half  to  compensate  for  the  fall  of 
the  mercury  in  the  other  limb,  thus  the  markings  give  the 
reading  directly  in  millimeters  of  mercury.  The  pressure 
is  obtained  by  the  use  of  a  metallic  pump  attached  to  the 
upper  nipple  by  means  of  a  collapsible  rubber  tube  of 
special  construction,  which  by  its  expansion  during  the 
operation  of  the  pump,  reduces  the  impact  of  air  before  it 
reaches  the  mercury  in  the  manometer,  and  takes  the 
place  of  the  second  bulb  of  the  cautery  apparatus.  An 
escape  valve  is  provided  for  gradually  lowering  pressure 
during  the  test. 

Disadvantages. — It  being  perhaps  somewhat  difficult 
for  one  to  see  the   defects  in   an   apparatus   of  his  own 


76  BLOOD-PRESSURE 

devising,  criticisms  of  this  instrument  are  not  here 
attempted,  but  are  left  to  others.  It  is  beUeved  that  the 
size  of  the  Standard,  and  its  weight  as  compared  with  the 
more  recently  devised  pocket  types  of  sphygmomanometer, 
should  not  be  considered  detrimental,  as  many  physicians 
prefer  the  mercury  type,  and  use  it  exclusively  in  physi- 
ologic research. 

6.  The  Folding  Mercury  Sphygmomanometer. — The  fold- 
ing mercury  instruments  of  Cooke  and  of  Jane  way,  already 
described,  are  not  at  present  in  great  favor,  because  of  the 
sectional  glass  tube,  which  favors  the  loss  of  mercury  and 
which  is  so  fragile.  These  defects  have  been  largely  over- 
come by  two  surgical  instrument  makers  who,  almost 
simultaneously  presented  perfected  instruments  which 
are  in  appearance  quite  similar  to  each  other.  One  is 
called  the  Midget^  (see  Fig.  15)  and  the  other  known  as 
the  Nicholson.-  These  instruments  follow  the  design  of 
the  Riva-Rocci  apparatus,  in  that  they  employ  the  res- 
ervoir and  vertical-tube  manometer.  In  the  Midget 
instrument,  with  which  I  am  more  familiar,  the  important 
point  is  the  improved  construction  in  the  hinge  which 
serves  to  join  the  two  segments  of  the  manometer  tube, 
so  arranged  that  the  old  cone-socket  ground-joint  con- 
nection is  abolished,  so  that,  when  in  position  for  operation, 
the  two  ends  of  the  tube  are  in  close  contact,  being  sep- 
arated only  by  a  thin  washer  which  prevents  the  escape  of 
mercury.  This  arrangement  not  only  reduces  the  danger 
of  breakage  to  a  minimum  but  also  avoids  obstructing 

1  Manufactured   by   George   P.    Pilling   &  Son   Co.,    Philadelphia. 
^  Manufactured  by  Precision  Thermometer  and  Instrument  Co.,  Phila- 
delphia. 


THE    SPHYGMOMANOMETER 


77 


the  view  of  the  mercury  column  at  any  point  on  the  scale, 
a  highly  desirable  condition  which  is  not  met  by  earlier 
jointed  instruments.  The  apparatus  is  placed  in  the  opera- 
tive position  simply  by  opening  the  lid  which  locks  when 
vertical.  The  tube  with  its  scale  is  then  unfolded  and 
pressed  vertically  upward  until  a  spring-catch  maintains  it 


Fig.   15. — Folding     mercury     sphygmomanometer    in    operative    position, 
showing  details  of  construction  and  attachment  to  arm. 


in  this  position.  After  use  a  lever  arrangement  releases 
this  lock  and  permits  of  folding,  which  movement  auto- 
matically closes  the  mouth  of  the  proximal  tube.  The  scale, 
while  being  a  separate  unit  and  adjustable  vertically  to 
accommodate  changes  in  the  mercury  level,  nevertheless 
follows  the  manometer  tube  in  all  positions.     The  apparatus 


78  BLOOD-PRESSURE 

registers  up  to  260  mm.  and  when  folded  is  self-contained  in  a 
mahogany  case  measuring  7  X  2%  X  1%.  The  apparatus 
employs  the  standard  flexible  cuff  and  is  inflated  by  a 
small  hand-pump. 

7.  The  Kercher  Mercury  Sphygmomanometer. — This 
little  instrument  is  another  modification  of  the  cistern-tube 
type  of  apparatus  and  was  suggested  in  1910  by  Delno  E. 
Kercher,^  is  supported  on  a  wooden  base  and  is  composed  of 
a  small  glass  cistern  containing  the  mercury  and  an  upright 
manometer  tube  reading  to  300  mm.  The  instrument  is 
provided  with  a  pneumatic  cuff  of  4  X  36  in.  and  is  actuated 
by  a  rubber  bulb  with  double  valve,  provided  with  a  T- 
connection  for  attachment  of  the  arm-band  and  manometer. 

8.  The  Aneroid  Sphygmomanometer. — This  type  of  appa- 
ratus has  much  to  recommend  it  and  should,  if  the  physician 
is  supplied  with  an  accurate  model,  be  most  satisfactory  for 
all  purposes,  as  the  present  methods  of  pressure  reading  do 
not  depend  upon  the  oscillation  of  the  mercury  column. 

The  term  aneroid  is  a  misnomer  and  should  never  have 
been  applied,  but,  as  it  has  become  so  firmly  associated 
with  this  apparatus,  it  probably  will  remain.  Aneroid 
signifies  the  absence  of  air,  i.e.,  the  presence  of  a  vacuum, 
yet  there  is  no  vacuum  chamber  in  this  sphygmomanometer, 
or  in  any  as  far  as  I  know. 

The  vital  portion  of  these  instruments,  or  the  part  which 
actuates  the  indicator,  consists  of  a  group  of  metallic 
chambers,  made  of  a  special  alloy  of  paper  thinness,  which 
when  exposed  appears  not  unlike  the  aneroid  portion  of  the 
well-known  barometer. 

Concerning  the  mechanism  of   this   type  of   sphygmo- 

1  Jour.  A.  M.  A.,  Apr.  2,  1910,  Vol.  liv,  14,  p.  113(). 


THE    SPHYGMOMANOMETER 


79 


manometer  close  examination  reveals  radical  differences 
in  the  mechanism  of  instruments  belonging  to  this  class. 
References   to    Figs.    16    and    17   show   diagrammatically 


niinr 


Fig.  16. — Diagrammatic  representation  of  internal  construction  of  Faught 
pocket  sphygmomanometer.  Note  the  four  compression  chambers  which 
are  intercommunicating  one  with  the  other  and  with  the  atmosphere  through 
the  body  of  the  instrument;  also  the  two  nipples,  through  which  the  com- 
pressing force  is  directed  upon  the  outside  of  the  chambers  causing  their 
collapse,  thereby  actuating  the  vertical  rod  which  extending  upward  connects 
with  the  gears  as  shown. 

this  difference.  Fig.  16  which  is  an  enlarged  transverse 
section  of  a  Faught  pocket  sphygmomanometer  as  com- 
pared with  Fig.  17  shows  that  in  the  author's  instrument, 


80  BLOOD-PRESSURE 

the  indicator  is  actuated  through  two  gear-wheels,  which  are 
in  turn  operated  by  a  plunger  which  is  seen  to  pass  through 
and  be  attached  to  the  bottom  of  the  lowest  chamber.     It 


Fig.  17. — Diagrammatic  representation  of  internal  construction  of  a  well- 
known  pocket  sphygmomanometer.  Note  the  two  compression  chambers, 
the  single  nipple  and  the  arrangement  whereby  the  compressing  air  is 
directed  within,  and  expands  the  chambers. 


will  be  seen  also  that  these  chambers  communicate  with 
each  other  and  with  the  air  in  the  body  of  the  apparatus. 
The  two  attachments  which  serve  as  connections  for  the 
pump  and  the  arm-band  are  seen  to  be  interchangeable  and 


THE    SPHYGMOMANOMETER  81 

to  communicate  with  a  closed  space  which  surrounds,  but 
which  does  not  communicate  with,  the  interior  of  the 
chambers.  This  is  the  vital  point  which  assures  accuracy 
in  this  instrument  for,  when  air  pressure  is  increased  around 
the  chambers,  they  tend  to  become  collapsed  and,  driving 
the  plunger  upward,  operate  the  indicator  through  the 
gears.  The  amount  of  movement  depends  upon  the 
amount  of  pressure  exerted  upon  the  chambers,  of  which 
there  are  Jour. 

Reference  to  Fig.  17  will  show  that  the  principle  here  is 
the  reverse,  and  that  the  two  chambers  are  designed  to 
receive  the  increment  of  air,  which,  by  expanding  them, 
operates  the  plunger  attached  to  their  upper  face  which  in 
turn  actuates  the  indicator  through  a  series  of  gears.  In 
this  instrument  the  over-expansion  of  the  chambers  is  a 
constant  possibility  which,  occurring  even  once,  renders  the 
apparatus  permanently  incorrect,  while  in  the  Faught  the 
pressure  can  only  collapse  the  chambers  which,  even  when 
over-compressed,  cannot  more  than  force  them  into  contact, 
and  as  this  manipulation  is  applied  to  every  Faught 
apparatus  before  it  is  graduated,  the  danger  of  inaccuracy 
is  entirely  removed.  Another  point  in  favor  of  this  instru- 
ment is  the  employment  of  four  chambers  instead  of  two; 
this  greatly  reduces  molecular  motion  and  is  another  ele- 
ment in  reducing  the  possibility  of  inaccuracy. 

9.  Faught  pocket  sphygmomanometer  (Fig.  18)  has  a 
dial  of  white  enamel,  somewhat  similar  to  that  of  a  watch. 
The  scale  is  graduated  in  millimeters  of  mercury,  as  deter- 
mined by  accurate  cahbration  with  a  standard  mercury 
column.  The  numerals  are  in  red  and  black,  to  facilitate 
reading,  and  each  individual  graduation  represents  2  mm., 


82 


BLOOD-PRESSURE 


giving  a  working  scale  extending  from  zero  to  300.  No 
mathematical  calculations  are  necessary  to  compute  the 
pressure,  which  can  be  easily  read  directly  from  the  dial. 

In  order  to  insure  accurate  and  unvariable  readings  at  all 
points  on  the  scale,  a  factor  of  safety  of  150  mm.  has  been 
provided,  i.e.,  each  Faught  pocket  sphygmomanometer 
before  leaving  the  factory  is  tested  up  to  150  mm.  above  the 


Fig.  18. — Faught  pocket  sphygmomanometer  attached  to  arm  showing 
position  of  arm-band,  dial  attached  to  hook  and  arrangement  of  tube 
connections. 


300  on  the  scale,  or  to  450,  after  which  the  readings  must 
correspond  with  those  of  a  standard  mercury  column,  and 
the  needle  after  this  severe  test  must  return  immediately 
to  zero.  This  shows  clearly  that,  with  ordinary  use,  it  is 
practically  impossible  to  distort  the  compression  chambers 
of  the  instrument. 

The  accuracy  of  the  so-called  aneroid,   or  diaphragm 
type  of  sphygmomanometer  has  been  questioned  by  some, 


THE    SPHYGMOMANOMETER 


83 


but  as  already  stated  in  the  improved  type  of  this  instru- 
ment sudden  variations  are  very  unhkely  to  occur.  The 
so-called  ''fatigue  of  metal"  referred 
to  by  some  authorities  does  not  exist, 
and  any  error  which  manufacturers 
admit  might  develop  in  their  instru- 
ments, must  be  due  to  some  me- 
chanical defect. 

An  additional  member  of  the  so- 
called  aneroid  group  is  the  ''clinical" 
pocket  sphygmomanometer  which 
has  been  placed  on  the  market  at 
the  author's  suggestion.  This  in- 
strument is  shown  in  Fig.  20.  It  is 
identical  in  construction  to  the 
pocket  instrument  differing  only  in 
having  a  specially  large  dial  {3}^  in.) 
and  consequently,  a  more  easily  read 

scale,   reading  to  350  mm.   Hg.      The  markings  on  this 
scale  are  sufficiently  distinct  to  be  easily  read  at  a  distance 


Fig.  19. — Faught  pocket 
apparatus  dial  in  detail. 


Fig.  20. — Clinical  sphygmomanometer;  side  and  front  views;  J-q  actual  size. 


84 


BLOOD-PRESSURE 


/  FAUGHT  POCKET 

I       BLOOO  RfteSSURE   APPAAATVS 

BLOOO  PRESSURE  STETHOSCOPE 

GRP/ttlNGSSON  CO.,PHILADA.,PA. 


BUILT  LIKE  A  WATCH 


Fig.  21. — Faught  pocket  sphygmo- 
manometer in  case. 


of  10  to  15  ft.,  an  advantage  that  will  recommend  itself  to 
class  teaching. 

The  instrument  employs  the  flexible  bandage-cufif  or 
arm-band,    (see    Fig.   18),  the  inflatable  portion  of  which 

measures  5  X  9  in.  A  small 
metal  pump  with  exhaust 
valve  attached  is  supplied 
and  these  parts  are  all  con- 
tained in  a  Morocco  pocket 
case.  The  needle  of  the  in- 
dicator is  extremely  delicate 
and  so  sensitive  that  a  dias- 
tolic reading  can  be  made  in 
any  case  in  which  a  mercury 
manometer   would    accomplish   it. 

10.  Erlanger's  Sphygmomanometer  (Fig.  22). — This  in- 
strument in  its  improved  form  is  apparently  the  most  accu- 
rate yet  devised  for  determining  blood-pressure,  being  based 
upon  the  same  principle  as  the  other  instruments,  but  both 
the  return  of  the  pulse  and  the  point  of  maximum  pulsation 
are  made  clearly  visible,  thus  almost  entirely  removing 
subjective  errors. 

The  construction  of  this  instrument  is  much  more 
complicated  though  the  only  essential  difference  is  the 
addition  of  an  original  recording  device.  The  U-tube  ma- 
nometer connects  with  a  four-way  tube,  of  which  one  branch 
leads  to  the  armlet,  and  another  to  a  special  stopcock.  The 
vertical  branch  communicates  with  the  interior  of  a  rubber 
bulb,  enclosed  within  a  heavy  glass  bulb,  which  in  turn, 
under  certain  conditions  communicates  freely  with  the 
atmosphere  through  another  tube  returning  to  the  special 


THE    SPHYGMOMANOMETER 


85 


stopcock.  The  object  of  this  glass-encased  rubber  bulb  is 
to  shield  the  delicate  tambour  from  too  sudden  changes  in 
pressure.  The  tambour  communicates  with  the  air  in  the 
glass  bulb  outside  of  the  rubber  ball,  and  operating  an  alumi- 
num needle  above  the  tambour,  inscribes  its  movements  on 
a  revolving  drum.  This  makes  a  tracing  upon  smoked 
paper  as  in  the  ordinary  kymographion.     The  whole  is 

o 


Fig.  22. — Erlanger's    sphygmomanometer    with    kymographion    in    place, 
showing  arm-Vjand  and  atomizer-bulb  inflator. 

attached  to  a  metal  base  and  is  covered  for  transportation 
by  a  metal  case  which  is  somewhat  larger  than  a  microscope 
box  and  of  about  the  same  weight. 

The  standard  cuff  is  employed  and  pressure  is  obtain^ed 
from  a  Pohtzer  bag.  All  rubber  tubing  is  of  the  high- 
pressure  variety  to  afford  rigidity. 

The  minute  details  of  construction  and  the  operation  of 


86  BLOOD-PRESSURE 

the  special  stopcock  are  too  extensive  to  include  here, 
suffice  to  say  that  with  practice  in  handling  the  instrument 
the  readings  obtained  are  accurate  and  furnish  a  permanent 
graphic  record  of  both  systolic  and  diastolic  pressures. 

Disadvantages. — The  chief  fault  to  be  found  with  this 
apparatus  is  from  the  standpoint  of  clinical  availability. 
Its  bulk  and  weight  render  it  almost  useless  for  clinical  work 
except  perhaps  in  the  office  or  the  hospital.  The  technique 
of  smoking  the  cylinder  and  of  making  necessary  adjust- 
ments consume  more  time  than  can  generally  be  spared 
during  the  activities  of  an  extended  practice.  And  in  addi- 
tion the  rubber  connections  and  the  diaphragm  of  the  tam- 
bour often  need  replacing  at  most  inconvenient  times. 

The  value  of  graphic  records  to-day  is  sufficiently 
obvious  and  needs  no  argument.  We  would  know  little 
of  the  characteristic  temperature  curves  of  malaria  or 
typhoid  fever  if  we  depended  for  our  information  upon  a 
long  column  of  figures.  The  course  of  blood-pressure  is 
equally  easy  to  chart  and  the  curve  thus  obtained  tells  us  at 
a  glance  much  that  the  perusal  of  the  usual  written  record 
would  fail  to  convey.  In  both  acute  and  chronic  diseases 
and  during  operations  the  systolic  blood-pressure  and  the 
pulse  should  be  charted  at  regular  intervals. 

This  chart  is  arranged  in  the  form  of  a  combined  pulse, 
temperature  and  blood-pressure  chart,  the  several  scales 
being  so  placed  that  the  pulse,  temperature  and  blood- 
pressure  curves  do  not  become  superimposed  (see  Fig.  23). 

The  chart  sheet  measures  9  X  12  in.,  which  is  the  size  of 
the  usual  hospital  history  sheet.  The  chart  may  be  filled 
in,  in  different  colors  if  desired  to  make  the  record  more 
graphic,  but  this  is  not  necessary  to  its  accurate  keeping. 


THE   SPHYGMOMANOMETER 


87 


These  charts  can  be  obtained  in  pads  of  twenty-five  from 
any  surgical  instrument  dealer  at  a  nominal  price. 


CHAfrr  no.  ^  '' 

OCCUPATION   -2  I 


PULSE,  TEMPERATURE  AND  BLOOD  PRESSURE  CHART 


Doilsul  l>T  Fcucii  A.  Fiullil.  M.  D. 


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Fig.  23. — Specimen  chart, 

11.  The  White  Mercury  Sphygmomanometer  (Fig.  24). 
— The  special  sphygmomanometer  devised  by  White  is 
particularly  designed  to  meet  the  requirements  of  colleges 


88 


BLOOD-PRESSURE 


and  schools,  where  the  demonstration  of  blood-pressure 
phenomena  is  made  before  a  large  body  of  persons.  This 
instrument  contains  some  of  the  elements  of  the  Faught 
mercury  sphygmomanometer,  to  which  have  been  added  an 
electrical  signal  device  as  shown  in  Fig.  24.     By  adjusting 


Fig.  24. — Pilling-White  Graphic  Sphygmomanometer.  Designed  to 
demonstrate  by  electrical  contacts  actuating  colored  lamps  the  excursions 
of  the  pulse  pressure. 

the  lamp  carriage  to  the  proper  position,  both  the  systole 
and  the  diastole  of  the  pulse  is  shown  by  min'.ature  electrical 
bulbs.  By  having  the  lights  of  different  colors  the  demon- 
stration is  even  more  graphic  and  the  extent  of  the  oscilla- 
tion of  the  pulse  wave  is  shown  by  the  number  of  lamps 
illuminated  during  each  cardiac  impulse. 


CHAPTER  V 
THE  CLINICAL  DETERMINATION  OF  BLOOD -PRESSURE 

The  Scope  of  the  Test. — The  clinical  determination  of 
blood-pressure  involves  an  estimation  of  the  systolic  and 
the  diastolic  pressures,  from  which  may  be  determined  the 
pulse  pressure  and  the  mean  pressure.  The  value  of  the 
observation  is  enhanced  if  the  pulse  rate  is  recorded  as  a 
part  of  this  examination. 

Any  peculiarities  noted  either  while  palpating  the  pulse  or 
in  variations  from  normal  in  the  series  of  sounds  heard 
during  auscultation  of  the  vessel  should  be  recorded. 
Valuable  supplementary  information  may  be  developed 
through  a  careful  consideration  of  these  factors. 

For  convenience  in  recording  blood-pressure  observations 
the  author  has  devised  and  now  employs  the  printed  card 
index  form  shown  in  Fig.  7,  page  59. 

Apart  from  the  style  of  the  apparatus  there  are  several 
methods  from  which  to  choose  for  determining  blood- 
pressure.  While  any  may  be  employed,  there  is  consider- 
able difference  in  their  accuracy  and  appUcability.  It 
seems  advisable  when  there  is  choice,  to  employ  that  one 
which  has  been  most  amply  shown  by  clinical  and  experi- 
mental evidence  to  be  the  most  accurate  and  satisfactory, 
i.e.,  the  auscultatory.  The  several  methods  which  may 
be  employed  are  the  following: 

The  auscultatory. 

The  palpatory. 


90  BLOOD-PRESSURE 

The  visual. 
The  graphic. 
The  oscillatory. 

A  detailed  description  of  each  together  with  its  advan- 
tages and  disadvantages  follows. 

A.  THE  AUSCULTATORY  METHOD 

In  1905  Korotkoff^  reported  that  when  the  bell  of  a 
stethoscope  was  placed  over  the  brachial  artery  at  its 
bifurcation  just  below  the  cuff  of  a  sphygmomanometer 


Fig.  25. — Showing  relation  of  sphygmomanometer  and  bracelet  stetho- 
scope arranged  for  the  auscultatory  blood-pressure  test. 

(see  Fig.  25)  and  the  pressure  in  the  cuff  gradually  reduced, 
a  series  of  characteristic  sounds  were  heard.  He  described 
three  tone  phases  and  stated  that  they  bore  a  definite 
r3lation  to  the  character  of  the  pulse,  the  condition  of  the 
heart  and  to  the  systolic  and  the  diastolic  blood-pressure. 
Subsequent  observers,   among  them  Ettinger,-  Lang  and 

^  Mitt.  d.  kc,  mil.  Med.  Akad.  zu  St.  Petersburg.,  1905,  xi,  365. 
2  Wien.  klin.   Wochen.,   1907,  xx,  992. 


THE    CLINICAL   DSTERMINATIOlSr    OF  BLOOD-PRESSURE  91 

Manswetowa,  ^  Fisher, ^  Gittings,  ^  Goodman  and  Howell/  and 
Swan^  have  further  analyzed  these  sounds  and  have  shown 
that  the  three  tone  phases  of  Korotokoff  may  usually  be 
separated  into  five. 

The  operator,  in  employing  this  method  notes  the  point, 
on  the  millimeter  scale,  either  the  mercury  column  or  the 
dial  indicator,  of  appearance  of  (a)  the  first  tap,  (6)  the 
appearance  of  the  systolic  murmur,  (c)  the  disappearance  of 
the  systolic  murmur,  (d)  the  point  at  which  the  sound 
suddenly  diminishes  in  intensity  and  (e)  the  point  at  which 
the  sound  ceases.  These  several  criteria  determine  the 
five  phases  of  Ettinger.  Korotokoff's  original  analysis  of 
these  auscultatory  arterial  sounds  distinguished  only 
three — the  first  or  systolic  point  corresponding  to  the  first 
tap,  the  second  to  the  development  of  the  systolic  murmur, 
and  the  third  to  the  disappearance  of  all  sound. 

Swan  in  his  recent  and  most  exhaustive  treatment  of  this 
subject^  calls  attention  to  the  confusion  existing  in  litera- 
ture concerning  the  phases.  This,  he  says,  is  due  to  the  fact 
that  some  authors  use  the  term  phase  to  indicate  the  points 
at  which  the  various  changes  in  the  character  of  the  sounds 
occur,  while  other  writers  speak  of  the  period  between 
these  two  points  as  a  phase.  Thus  the  early  writers  call 
the  point  at  which  the  first  sound  is  heard  the  first  phase; 
that  at  which  the  murmur  appears  as  the  second  phase; 
that  at  which  the  murmur  disappears  as  the  third  phase; 


*  Deutsch.  klin.  Med.,  1908,  xciv,  445. 

*  Zeitsch.  f.  dietet.  u.  physick.  Therap.,  1909,  xii,  p.  389. 

3  J.  C.  Gittings,  Arch.  Int.  Med.,  August,  1910,  p.  196. 

*  Am.  Jour.  Med.  Sci.,  1911,  cxlii,  p.  334. 
^  Internat,  Clinics,  iv,  Series,  24. 

*  hoc.  cit. 


92  BLOOD-PRESSURE 

that  at  which  the  sound  following  the  murmur  becomes 
suddenly  lessened  in  intensity  the  fourth  phase;  that  at 
which  the  sound  entirely  disappears  the  fifth  phase.  On 
the  other  hand,  recent  writers  call  the  duration  of  the  first 
sound  as  measured  in  millimeters  of  mercury,  the  first 
phase;  the  duration  of  the  murmur  the  second  phase;  the 
duration  of  the  second  clear  sound  the  third  phase;  and 
the  duration  of  the  dull  end  sound  the  fourth  phase.  In 
order  to  avoid  confusion  Swan  suggests  the  adoption  of  the 
word  point,  to  indicate  the  changes  in  the  sounds  and  the  use 
of  the  term  phase  to  indicate  the  duration  of  the  sounds 
respectively. 

The  general  adoption  of  this  suggestion  will  contribute 
greatly  to  clarity  in  our  discussions  and  writings  upon  the 
auscultatory  method  of  study;  which  if  accepted,  will 
admit  of  the  following  classification: 

First  point:  Appearance  of  first  tap,  or  sound  in  pre- 
viously silent  stethoscope. 

First  phase:  A  sharp  sound  not  unlike  the  cardiac  first 
sound. 

Second  point:  The  instant  of  the  addition  of  a  systolic 
murmur  to  the  first  phase. 

Secon^d  phase:  The  duration  of  the  hissing  murmur  plus 
the  first  sound. 

Third  point:  The  moment  of  disappearance  of  the  sys- 
toUc  murmur. 

Third  phase:  The  duration  of  a  sound  similar  but  some- 
what more  powerful  than  the  first. 

Fourth  point:  The  moment  that  the  sound  of  the  third 
phase  suddenly  becomes  muffled  and  reduced  to  a  dull  tone. 

Fourth  phase:  The  duration  of  the  muffled  soft  tone. 


THE    CLINICAL   DETERMINATION    OF  BLOOD-PRESSURE  93 

Fifth  point:  All  sound  disappears. 

The  Significance  of  the  Points  and  Phases. — The  first 
point,  which  is  the  appearance  of  the  first  clear  sound,  has 
been  accepted  by  all  observers  to  indicate  the  systolic 
blood-pressure.  Cook  and  Taussig^  describe  it  as  the 
''most  accurate  for  determining  this  pressure.  It  is  as 
much  superior  to  the  palpation  of  the  radial  as  the  sense  of 
hearing  is  keener  than  the  sense  of  touch." 

Warfield-  has  proved  by  experiments  on  dogs  that  the 
first  phase  corresponds  to  the  systoUc  blood-pressure. 

The  fourth  point  which  is  the  time  at  which  the  tap, 
heard  after  the  disappearance  of  the  systolic  murmur, 
becomes  dull,  is  considered  by  Land  and  Manswetowa' 
Zabel,^  Taussig  and  Cook,^  Stone,^  Hirschfelder^  and 
Warfield^  to  indicate  the  diastolic  pressure. 

The  fifth  point  or  the  moment  of  disappearance  of  all 
sounds  is,  on  the  other  hand,  considered  to  indicate  the  dias- 
tolic pressure  by  Korotkoff,^  Ettinger,^"  Gittings,"  Good- 
man, and  Howell,  ^^  Hooker  and  South  worth,  ^^  Krylow,^^ 


1  Arch.  Int.  Med.,  1913,  xi,  542. 

2  Arch.  Int.  Med.,  1912,  x,  258  and  Interstate  Med.  Jour.,  1912,  xix,  856. 

3  Deutsch.  Arch.  f.  klin.  Med.,  1908,  xciv,  441,  455. 
*Berl.    klin.    Wochen.,    1909,   xlvi,    1352. 

^Arch.   Int.   Med.,   1913,  xi,   542. 
6  Jour.  A.  M.  A.,  1913,  Ixi,  1256 

'"Diseases  of  the  Heart  and  Aorta,"  edition  2,  1913,  33. 
*  hoc.  cit. 

^  Mitt.  d.  k.  mil.  med.  Akad.  zu.  St.  Petersburg,  1905,  ix,  365. 
10  men.    klin.    Wochen.,    1909,    Feb.    11. 
^^Arch.  Int.  Med.,   1910,  vi,   195. 

^'^  Univ.Penn.  Med.  Bull.,  1910,  xxiii,  469  and  Amer.  Jour.  Med.  Set.,  1911, 
cxlii,  334. 

"Arch.  Int.  Med.,  1914,  xiii,  384. 

^*  Quoted  by  Gittings  and  Goodman  and  Howell. 


94  BLOOD-PRESSURE 

Fellner,^  Fisher, ^  Ehret,^  Schrumpf  and  Zabel,"*  Moritz,^ 
Sterzing,^  Prendergasf^  and  Bickel.*  Bickel,^  found  that 
the  fourth  point  corresponds  to  the  diastoHc  pressure 
obtained  by  the  graphic  method  and  approximates  the 
diastoHc  pressure  as  obtained  by  the  palpatory  method. 

The  fifth  point,  however,  corresponds  to  the  diastoHc 
pressure  as  obtained  by  the  osciUatory  method.  ZabeP" 
made  his  observation  in  a  manner  the  reverse  of  that  of 
other  observers  and  while  he  obtained  similar  results, 
Swan"  has  noted  important  objections  to  making  dias- 
tolic readings  in  this  manner,  the  chief  of  which  is  that  the 
adventitous  sounds  made  by  inflating  the  cuff  obscure  the 
sharp  fifth  point. 

In  a  careful  review  of  this  work  Swan  concludes  that,  as 
conditions  are  not  as  ideal  in  clinical  work  as  those  found  by 
Warfield  in  his  experiments,  as  the  cuff  is  applied  through 
intervening  tissues  and  because  the  fourth  point  is  often 
absent  in  clinical  work,  it  is  advisable  for  bedside  work  to 
record  the  fifth  point  as  the  diastolic  pressure. 

The  contention  that  the  interpretation  of  the  diastolic 
pressure  as  indicated  by  the  fourth  point  makes  an  impor- 
tant difference  in  determining  mean  pressures  and  pulse 

I  Verhandl  d.  24  Kong.  /.  inn.  Med.,  1909,  xxiv,  404. 

^  Deutsch.  med.  Wochen.,  1908,  xxxiv,  1141  and  Zeitsch.  f.  diatel.  u.  phy- 
sick.  Therap.,  1909,  xii,  389. 

'  Munchen.  med.  Wochen.,  1909,  Ivi,  959. 

*  Munchen.  med.   Wochen.,  1909,  Ivi,  704. 

*  Munchen.  med.  Wochen.,  1909,  Ivi,  321. 
«  Deutsch.  med.  Wochen.,  1909,  xxxv,  1874. 
'  N.  Y.  Med.  Jour.,  1913,  xcvii,  78. 

8  Zeitsch.  /.  exper.  Path.  u.  Therap.,  Bd.  c.  H,  quoted  by  Zabel,  Berl. 
klin.  Wochen.,  1909,  xlvi,  1352. 

*  hoc.  cit. 

"  Deri.  klin.  Wochen.,  1909,  xlvi,  1352. 

II  John  M.  Swan,  Inter.  Clinics,  iv,  Series  24. 


THE   CLINICAL   DETERMINATION    OF  BLOOD-PRESSURE  95 

pressures  is  quite  well  founded.  Swan  found  that  in  118 
observations  in  which  both  the  fourth  point  and  the  fifth 
point  were  recorded  the  average  difference  amounted 
to  14  mm. 

Warfield  found  that  the  difference  between  the  fourth 
and  fifth  points  in  some  cases  amounted  to  12  mm.,  in  other 
cases  the  difference  amounted  only  to  from  2  to  4  mm. 

Analysis  of  the  Tone  Phases. — The  first  sound  or  phase 
is  ascribed  to  the  return  of  the  pulse  below  the  obstruction 
which  suddenly  distends  the  collapsed  brachial  artery. 
Gittings^  beheves  that  these  sound  waves  are  reinforced  by 
the  resonating  quality  of  the  cuff,  since  compression  with  an 
Esmarch  bandage  usually  fails  to  produce  this  character  of 
sound,  although  Mac  Williams  and  Melvin^  using  a  sche- 
matic circulation,  were  able  to  obtain  the  characteristic 
sounds  when  no  cuff  was  used.  They  attribute  the  sounds 
to  the  ''vibration  of  the  arterial  wall  when  the  normal  cir- 
cular (cylindrical)  form  of  the  vessel  is,  in  the  compression 
area,  more  or  less  distorted  by  external  pressure." 

The  Second  Phase. — The  addition  of  a  murmurish 
quahty  to  the  first  sound  due  to  the  relatively  large 
size  of  the  artery  below  the  constriction  which  produces 
fluid-veins. 

The  Third  Phase. — The  disappearance  of  the  murmurish 
quality  of  the  second  sound  is  probably  the  hardest  to 
explain.  It  would  appear  to  be  due  to  the  gradual  lessen- 
ing of  the  constricting  pressure  and  the  consequent  elimi- 
nation of  the  fluid-veins.  This  phase  is  usually  very  dis- 
tinct and  often  louder  than  the  first.     It  is  the  phase  of  the 

*  Arch.  Int.    Med.,  August,    1910. 
2  Heart,  1914,  v.  153. 


96  BLOOD-PRESSURE 

greatest  duration  and  corresponds  to  the  time  of  greatest 
oscillation  in  the  indicators  and  in  the  graphic  apparatus. 

The  Fourth  Phase. — A  muffling  of  the  sound  which  occurs 
when  the  pressure  from  the  constricting  band  has  become 
so  slight  that  it  fails  to  compress  the  artery  sufficiently, 
even  diu-ing  the  diastolic  period,  to  either  slow  the  blood- 
stream or  produce  fluid- veins  (see  Fig.  9,B,  page  67). 

The  disappearance  of  all  sounds  occurs  when  normal 
arterial  relations  are  reestablished. 

In  cases  of  aortic  regurgitation  the  fourth  phase  is  usu- 
ally persistent,  and  it  is  not  uncommon  to  hear  a  sharp 
sound  over  the  arteries  when  no  pressure  is  being  exerted 
by  the  cuff.  This  phenomenon  may  occasionally  be  noted 
in  other  conditions  and  therefore  cannot  now  be  considered 
as  pathognomonic  of  aortic  regurgitation.  The  persistence 
of  the  fourth  phase,  or  the  observation  of  the  fifth  point  at 
zero,  has  been  observed  in  broncho-pneumonia  and  exoph- 
thalmic goiter^  in  high  fever  and  cardiac  neuroses;^  in 
arteriosclerosis;^  in  hypertrophic  cirrhosis  and  hyperthy- 
roidism^ while  Cook  and  Taussig^  have  found  it  at  10 
mm.  Hg.  in  a  series  of  cases  of  aortic  regurgitation. 

Variations  in  Tone  Phases  and  their  Significance. — 
When  auscultating  for  the  determination  of  blood-pressure, 
not  only  may  these  variations  be  detected,  but  in  addition 
slight  arrhythmias  and  variations  in  the  force  of  each  systole. 
This  fact  is  known  to  many.  (The  author  called  attention 
to  this  point  in  his  ward-class  teaching  over  six  years  ago). 

*  Cook  and  Taussig,  Arch.  Int.  Med.,  1913,  xi,  542. 

*  Fischer,  Deutsch.  Med.  Wochen.,  1908,  xxxiv,  1141. 
'  Zabel,  loc.  cit. 

*  Swan,  loc.  cit. 

*  Loc.  cit. 


THE   CLINICAL   DETERMINATION    OF  BLOOD-PRESSURE  97 

Quite  recently  it  has  again  been  brought  forward  by  the 
work  of  Jas.  B.  Herrick.^ 

First  Phase. — It  has  been  noted  that  a  strong  first  phase 
is  not  always  an  indication  of  health,  and  Fischer^  has 
noted  the  fact  that  in  cases  of  very  high  pressure,  as  in 
chronic  nephritis,  the  sounds  of  the  first  phase  are  unusu- 
ally loud. 

Second  Phase. — Fischer^  and  Goodman  and  Howell^  have 
found  the  murmurs  of  the  second  phase  usually  very  clear 
and  the  phase  itself  prolonged  in  cases  of  anemia.  Tornai^ 
states  that  a  strong  murmur  phase  indicates  a  good  heart, 
and  that  a  phase  of  increased  length  after  exercise  indicates 
a  good  heart,  whereas  if  the  murmur  disappears  after 
exercise  it  is  an  indication  of  a  weakened  left  ventricle.  A 
murmur  phase  which  gradually  increases,  and  gradually 
recedes — that  is  not  clear  cut  at  the  ends — is  noted  in  cases 
of  dilatation  and  hypertrophy.  The  absence  of  this  phase  is 
an  indication  of  heart  weakness.  Goodman  and  Howell,^ 
and  Swan'^  believe  that  the  second  phase  is  the  first  to 
suffer  in  failing  compensation.  They  believe  the  length  of 
this  phase  indicates  cardiac  efficiency,  and  they  have 
worked  out  a  cardiac  efficiency  ratio,  which  is  based  upon 
this  belief  (vide  infra). 

Third  Phase. — Fischer^  considers  the  third  phase  the 
most  important  clinically.     A  long,  loud  and  clear  third 

^Jour.  A.  M.  A.,  Feb.  26,   1915,  Ixiv,  9. 

^Loc.  dt. 

^  Loc.  cit. 

*  Am.  Jour.  Med.  Set.,  1911,  cxlii,  334. 

^  Zeitsch.  f.  diatet.  u.  physick.  Therap.,  xiii. 

^  Loc.  cit. 

''  Loc.  cit. 

8  Loc.  cit. 


98  BLOOD-PRESSUBE 

phase,  indicates  cardiac  strength,  while  a  weak  and  short 
third  phase  with  soft  sounds  is  indicative  of  cardiac  weak- 
ness. Ettinger,  Warfield,  Goodman  and  Howell,  and  Swan 
concur  in  this  view. 

Fourth  Phase. — The  duration  of  the  fourth  phase  increases 
with  cardiac  weakness  and  according  to  Fischer^  is  almost 
always  a  concomitant  of  a  low  diastolic  pressure. 

The  Cardiac  Strength — Cardiac  Weakness  Ratio. — Bas- 
ing their  conclusions  upon  the  preceding  premises,  Good- 
man and  Howell  in  1910^  worked  out  a  percentage  dura- 
tion of  the  pulse  pressure  for  each  tone  phase,  considering 
that  the  second  and  third  phases  are  dependent  upon  card- 
iac strength  or  effectiveness,  while  the  first  and  fourth 
phases  are  dependent  upon  cardiac  weakness  or  defective- 
ness. They  have  made  a  proportion  to  indicate  the  num- 
erical value  of  these  two  factors  in  any  given  case.  These 
percentage  values  are  calculated  to  a  normal  average  pulse 
pressure  of  45  mm.  in  which  they  found  that  the  phases 
formed  the  following  percentages  of  this  pulse  pressure: 

First  phase 33.1  per  cent. 

Second  phase 44,4  per  cent. 

Third  phase 11.1  per  cent. 

Fourth  phase 13.3  per  cent. 

Thus  44.4  +  11.1  =  55.5  per  cent.,  and 
33.1  +  13.3  =  44.4  per  cent. 

Therefore,  cardiac  strength  (C.S.):  cardiac  weakness 
(C.W.)::  55.5:44.4.  While  this  view  is  not  yet  accepted 
as  consistently  proven,  nor  generally  employed  as  a  basis 
for  clinical  investigation,  nevertheless  Swan^  has  in  his 
comprehensive  study  of  200  cases,  done  much  to  prove  the 

'  hoc.  cit.  2  Loc.  cit  ^  Loc.  cit. 


THE    CLINICAL   DETERMINATION    OF  BLOOD-PRESSURE  99 

contention  of  the  originators.  Unfortunately,  space  will 
not  permit  of  an  extended  review  of  this  work.  From  it, 
however,  we  can,  as  suggested  by  Swan,  draw  the  following 
conclusions: 

"1.  The  auscultatory  method  is  the  most  accurate  and  most  convenient 
method  of  making  blood-pressure  determination. 

"2.  The  first  point  should  be  considered  the  systolic  or  maximal  pressure. 

"3.  The  fifth  point  should  be  considered  the  diastolic  or  minimal  pressure, 
except  in  cases  in  which  a  sound  can  be  heard  in  the  brachial  artery,  with 
no  pressure  in  the  cuff,  in  which  case  the  fourth  point  should  be  considered 
to  represent  the  diastolic  pressure. 

"4.  The  pulse  pressure  and  the  mean  pressure  can  always  be  obtained  by 
the  auscultatory  method. 

"5.  The  systolic  pressure  obtained  by  the  auscultatory  method  is  almost 
always  higher  than  that  obtained  by  the  palpatory  method,  and  lower  than 
that  obtained  by  the  graphic  method. 

"6.  Whenever  it  is  possible  to  work  out  the  C.S.  =  C.W.  ratio  valuable 
information  can  be  obtained  concerning  the  functional  ability  of  the  myo- 
cardium at  the  time  the  observation  is  made. 

"7.  It  may  be  said,  as  a  rule,  that  a  second  phase  forming  more  than  40 
per  cent,  of  the  pulse  pressure,  and  a  C.S.  =  C.W.  ratio,  in  which  the  C.S 
factor  is  greater  than  the  C.W.  factor,  give  a  fairly  reliable  index  of  the 
competence  of  the  myocardium. 

"8.  Although  one  cannot  make  the  C.S.  =  C.W.  equation  when  one  point 
or  more  is  absent,  a  second  phase  of  40  per  cent,  or  more  of  the  pulse  pres- 
sure indicates  a  good  heart  muscle  and  one  capable  of  being  put  in  better 
physiological  condition. 

"9.  Absent  points  and  tonal  arrhjrthmias  indicate  cardiac  muscle  weak- 
ness." 

Comparison  of  Results  Obtained  by  the  Auscultatory 
Method  with  Those  Obtained  by  the  Other  Methods. — 
Palpatory  Method. — In  practically  every  case  the  auscul- 
tatory method  gives  readings  higher  than  by  the  palpatory. 
KorotokofT^  found  that  the  systolic  readings  by  the  former 
averaged  from  10  to  12  mm.  Hg.  higher;  Gittings^  in  a 
study  of  sixty-three  cases  found  that  in  sixty-one  the 
average    systolic    pressure  was   I6K0   nani.   Hg.   higher; 

^  Loc.  cit.  2  j^oc.  cit. 


100 


BLOOD-PRESSURE 


Warfield^  obtained  values  of  from  6  to  14  mm.  Hg.  higher. 
The  greatest  difference  was  noted  in  arteriosclerosis.  Swan^ 
studied  the  difference  between  these  two  methods  in  100 
consecutive  cases,  in  ninety-eight  of  which  the  systolic 
pressure  by  ausc\^ltation  was  from  1  to  30  mm.  Hg.  below 


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Fig.  26. — Comparative  table  of  systolic  readings  made  by  the  graphic 
method,  the  ausculatory  and  the  palpatory  methods,  showing  differences 
in  millimeters  between  each  method.  Uskoff  apparatus  12  cm.  cuff 
(modified  from  Swan). 

that  given  by  the  auscultatory  method.  The  average 
difference  was  9.98  mm.  Hg.  My  own  experience  is  in  ac- 
cord with  these  investigators. 

Visual  Methods. — Writers  have  found  such  wide  differ- 
ence in  their  own  observations,  due  to  the  uncontrollable 

1  Interstate  Med.  Jour.,  xix,  10,  October,  1912,  p.  860. 
^  Loc.  cit. 


THE    CLINICAL   DETERMINATION    OF   BLOOD-PRESSURE        101 

elements  of  error,  resulting  from  the  type  of  instrument 
used,  manner  of  application  of  the  cuff  and  the  personal 
equation  of  the  examiner,  that  little  if  any  dependence 
should  be  put  in  this  method,  either  for  systolic  or  diastolic 
determinations. 

Graphic  Methods. — Apart  from  the  intricacy  of  these 
methods  which  renders  them  practically  useless  for  clinical 
and  bedside  work,  they  have  also  been  found  to  give  mis- 
leading data,  because  sphygmographic  tracings  always  give 
readings  that  are  too  high. 

The  Uskoff  instrument  for  example  gives  a  series  of  pul- 
sations long  before  the  blood-stream  enters  the  artery 
below  the  cuff. 

Swan  has  examined  comparatively  seventeen  cases,  by 
the  graphic,  the  auscultatory  and  the  palpatory  methods, 
his  results  are  shown  in  the  accompanying  table.  Fig.  26, 
which  has  been  modified  by  adding  figures  which  show  at  a 
glance  the  variation  between  the  methods  in  each  case. 

Additional  Auscultatory  Data. — The  actual  volume  of  the 
tones  heard  by  auscultation  depends  on  so  many  factors 
that  their  bearing  and  clinical  significance  can  be  practi- 
cally estimated  only  by  those  experienced  in  this  method  of 
observation.  This  accomplishment  when  once  mastered 
will  be  a  never  failing  source  of  satisfaction  and  assistance 
to  the  clinician. 

In  auscultatory  blood-pressure  work,  one  should  endeavor 
to  follow  and  analyze  the  sounds  in  the  same  manner  as 
when  examining  the  heart.  The  examiner  should  take  into 
consideration:  first,  the  size  and  strength  of  the  heart; 
second,  the  size  of  and  the  state  of  contraction  of  the  arte- 
rial wall;  third,  arterial  elasticity;  fourth,  the  conducting 


102  BLOOD-PRESSURE 

value  of  the  stethoscope,  the  degree  of  pressure  exerted 
over  the  artery  and  the  thickness  and  tone  of  the  overlying 
structures.  A  general  knowledge  of  these  elements  will 
enable  the  careful  clinician  to  arrive  at  finer  points  of 
decision  in  diagnosis,  than  if  the  auscultatory  tone  phases 
alone  are  depended  upon. 

Another  advantage  of  the  auscultatory  method,  beside 
its  great  accuracy,  is  the  fact  that  the  method  is  available  in 
every  case,  regardless  of  the  size  of  the  artery,  of  the  arm  or 
the  volume  of  the  pulse.  Further,  it  can  be  performed 
with  any  variety  of  sphygmomanometer  and  any  stetho- 
scope (small  receiver  preferred). 

It  should  be  borne  in  mind,  however,  that  cases  will  be 
met  in  which  it  will  be  impossible  to  differentiate  all  the 
points  and  phases.  The  most  usual  anomaly  according  to 
Swan^  is  the  absent  fourth  point.  This  is  when,  after  the 
murmur  has  disappeared,  the  clear  tap  gradually  dimin- 
ishes until  all  sounds  disappear.  Sometimes  the  murmur  is 
the  first  sound  heard  as  the  pressure  diminishes  in  the  cuff, 
absent  first  point.  Sometimes  the  first  point  is  heard  but 
no  murmur  can  be  detected,  suddenly  the  tap  becomes 
dulled,  and  finally  the  sound  disappears,  absent  second  and 
third  points.  Again  the  murmur  may  be  the  first  sound 
heard,  and  often  it  disappears,  the  tap  diminishes  in  inten- 
sity, until  the  sounds  disappear,  absent  first  and  fourth 
points.  Sometimes  all  the  points  are  absent  except  the 
first  and  fifth,  no  phases. 

B.  PALPATORY  METHOD 

Systolic  Pressure. — After  the  pressure  in  the  apparatus 
has  been  raised  until  the  pulse  is  no  longer  palpable  at  the 

1  Loc.  cit. 


THE    CLINICAL    DETERMINATION    OF  BLOOD-PRESSUBE        103 

wrist,  it  is  then  gradually  reduced;  at  the  same  time  the 
level  of  the  mercury  or  the  position  of  the  pointer  is  noted 
where  the  first  pulse  beat  is  felt  at  the  wrist.  This  is  the 
systolic  pressure. 

Diastolic  Pressure. — As  the  air  pressure  continues  to  fall 
from  a  point  below  the  systolic,  the  character  of  the  pulse  at 
the  wrist  is  carefully  noted.  At  first  this  is  very  feeble  and 
thready  in  character  and  continues  so  for  a  time,  when  sud- 
denly it  assumes  a  full  bounding  character.  At  this  moment 
the  height  of  the  mercury  column,  or  the  hand  of  the  indi- 
cator, will  represent  the  diastolic  pressure  in  millimeters  of 
mercury. 

C.  VISUAL  METHOD 

Systolic  Pressure. — After  obliteration  of  the  pulse  by  the 
constricting  cuff,  it  will  be  noted  as  the  pressure  is  gradually 
released,  that  an  oscillatory  motion  will  be  imparted  by 
the  pulse  to  the  mercury  column  or  of  the  needle  of  the 
indicator.  The  beginning  of  this  oscillation  has  been 
believed  to  indicate  the  systolic  point,  as  it  was  believed  to 
indicate  the  approximate  moment  when  the  blood  begins 
to  pass  beyond  the  constriction.  With  the  advent  of  the 
auscultatory  method  it  is  now  believed  that  readings  taken 
by  the  visual  method  are  only  approximate  and  often 
inaccurate,  as  in  many  cases  this  movement  appears  many 
millimeters  above  the  actual  systolic  point  (see  page  100). 

Diastolic  Pressure. — As  the  pressure  is  gradually  re- 
leased, the  rhythmic  motion  of  the  mercury  or  of  the  indi- 
cator which  appeared  at  the  systolic  point  will  be  seen  to 
gradually  increase  in  amplitude  up  to  a  certain  point,  after 
which  it  decreases  and  finally  ceases  before  zero  pressure  is 


104  BLOOD-PRESSUBE 

reached.     During  this  phenomenon  the  diastolic  pressure 
reading  is  taken  at  the  maximum  oscillation. 

D.  THE  GRAPHIC  METHOD 

Systolic  and  Diastolic. — The  determination  of  blood- 
pressure  by  the  graphic  method  is  accomplished  by  an 
apparatus  which  combines  some  form  of  mercury  sphyg- 
momanometer with  a  sphygmograph,  whereby  the  move- 
ments of  the  mercury  column  and  the  level  of  the  mercury 
are  recorded  upon  smoked  paper,  or  other  suitable  material, 
upon  a  moving  surface  or  a  revolving  drum.  This  method, 
while  thoroughly  scientific,  is  not  suited  to  clinical  use  (see 
page  84  for  description)  and  will  not  be  enlarged  upon  here. 

E.  THE  OSCn^LATORY  METHOD 

This  method  requires  an  instrument  by  which  the  chang- 
ing character  of  the  arterial  impulse,  as  it  passes  under  the 
cuff  of  the  sphygmomanometer,  is  accentuated,  so  that  vari- 
ations in  its  force,  transmitted  to  the  apparatus  by  air 
currents,  are  transformed  into  visible  motion  in  the  instru- 
ment, when  they  are  more  easily  analyzed  and  more  accu- 
rately read.  This  method  does  not  differ  materially  from 
the  usual  visual  method,  although  it  is  said  to  be  more 
accurate,  and  of  particular  value  in  studying  low  systolic 
and  small  pulse  pressures. 

Among  those  most  commonly  used  instruments  are  those 
of  Pal  (sphygmoscope)  and  of  Bing,  both  of  which  were  in- 
troduced and  described  in  1906,  also  the  instrument  of 
Pachon,  which  is  a  modification  of  the  aneroid  apparatus, 
in  which  two  series  of  compression  chambers,  one  group 
large  and  one  small,  are  used.     The  small  one  indicates  the 


THE    CLINICAL    DETERMINATION    OF   BLOOD-PRESSURE         105 


Fig.  27. — Fedde   indicator 
as  separate  unit. 


pressure  level  and  the  large  one  actuates  the  oscillatory 
needle. 

Fedde,  several  years  later,  intro- 
duced what  he  called  a  '' Diastolic 
Indicator."  This  is  simply  a  pith- 
ball  oscillometer,  in  which  the  mo- 
tion of  the  air,  transmitted  from  the 
cuff  to  the  indicator,  is  accentuated 
by  means  of  a  closed  metallic 
chamber  between  which  and  the 
arm-band  is  interposed  a  vertical 
glass  tube  containing  a  delicate 
pith-ball,  the  motion  of  which  visu- 
alizes the  impulses. 

This  instrument  is  shown  in  Fig,  27,  where  it  is  made  as  a 
separate  unit  for  attachment  to  any  variety  of  sphygmo- 

mano meter.  The  manufac- 
turers of  this  instrument  (G.  P. 
Pilling  &  Son  Co.)  have  also 
modified  the  construction  of  this 
instrument  so  that  it  may  be  in- 
cluded as  a  component  part  (at 
additional  cost)  in  the  Standard 
mercury  sphygmomanometer. 

Reference    to    Fig.    28,    will 
show  the  method  of  uniting  the 
Fig.  2S.-Sketch  of  standard    Fedde  indicator  to  a  sphygmo- 

mercury    sphygmomanometer     manometer.        It    will    be    noted 
combined  with  Fedde  indicator.  t       i 

that  the  narrow  perpendicular 
glass  tube  contains  a  small  light  ball  of  pith  or  cork  which 
is  free  to  move  up  and  down  within  the  tube. 


106  BLOOD-PRESSURE 

When  determining  the  systoUc  pressure,  pay  no  atten- 
tion to  this  indicator,  as  each  impact  of  air  will  make  the 
ball  dance  violently  but  has  no  bearing  on  the  test.  When 
the  pressure  has  reached  the  systolic  point  gradually  release 
the  air  pressure  when  the  ball  will  begin  to  move  slightly  in 
rhythm  with  the  pulse.  This  motion  gradually  increases, 
until  it  reaches  a  maximum  when  quite  suddenly  its  motion 
becomes  markedly  less.  At  the  moment  of  this  reduced 
movement  the  level  of  the  mercury  will  indicate  the  diastolic 
pressure. 

Diastolic  Index. — In  connection  with  blood-pressure  tests 
it  is  interesting  to  consider  a  point  brought  out  by  Mac- 
Williams  and  Melvin^  and  which  may  later  develop  into  an 
additional  diagnostic  aid.  These  observers  found  it  desir- 
able to  study  what  they  have  termed  ''the  diastolic  index." 
This  is  determined  after  the  systolic  reading  has  been 
taken,  by  making  the  diastolic  reading  both  when  the  com- 
pression is  being  increased  and  decreased.  They  found  a 
difference  amounting  at  times  to  as  much  as  20  mm. 
between  the  diastolic  readings  obtained  by  these  two 
methods.  They  believe  that  this  difference  gives  impor- 
tant information  concerning  the  liability  of  the  pressure  to 
vary  in  an  abnormal  way  when  a  portion  of  the  arterial 
tree  is  shut  off  from  the  general  circulation.  Similar 
changes  have  been  noted  by  other  observers  in  the  systolic 
pressure  when  a  large  portion  of  the  arterial  system  is  sud- 
denly obstructed  (see  Momberg  constriction,  page  225). 
The  pulse  rate  also  at  times  varies. 

The  demonstration  of  such  marked  changes  would  appear 
to  suggest  a  poor  response  on  the  part  of  the  vasomotor 

1  J.  C.  Mac  Williams  and  G.  S.  Melvin,  Brit.  Med.  Jour.,  Nov.  7,  1914. 


THE    CLINICAL    DETERMINATION    OF   BLOOD-PRESSURE 


107 


mechanism  to  accommodate  by  rapid  changes  in  the  caUber 
of  the  vessels  for  sudden  changes  in  the  volume  of  the  cir- 
culating blood.  This  discovery  has  opened  up  a  field  for 
additional  research,  the  value  of  the  findings  of  which  can- 
not be  determined  without  further  study  and  investigation. 

The  Subjective  Method  of  Determining  Blood-pressure. 
— It  has  long  been  known  that  the  subjective  sensation  of  the 
patient  may  at  times  furnish  a  reliable 
guide  in  determining  systolic  and  diastolic 
pressures.  Thus  when  the  cuff  has  been 
sufficiently  inflated  to  obstruct  the  pulse, 
there  is  felt  a  slight  impulse  in  the  upper 
margin  in  the  cuff  corresponding  to  the 
line  of  the  artery.  As  the  pressure  is 
lowered  in  the  air  system,  thus  pulsation 
proceeds  downward  so  that  it  finally  is 
felt  below  the  cuff,  where  it  measures  the 
systolic  pressure.  Continued  reduction  in 
air  pressure  eventually  results  in  disap- 
pearance of  any  sensation  under  or  below 
the  cuff.  This  indicates  the  diastolic 
pressure.  While  such  readings  may  be 
quite  accurate,  this  procedure  involves  a 
considerable  and  often  an  uncontrollable  personal  equation 
and  should  therefore  not  be  depended  upon. 

The  Sphygmometroscope  will  be  found  of  great  assistance 
in  performing  the  auscultatory  method.  This  instrument 
as  shown  in  the  accompanying  cut  (Fig.  29)  is  a  Bowles 
stethoscope  with  a  button-like  projection  attached  to  the 
face  of  the  diaphragm.  This  greatly  facilitates  its  appli- 
cation to  the  artery  below  the  sphygmomanometer  cuff, 


Fig.  29.— Bracelet 
stethoscope  for  aus- 
c  u  1 1  a  t  o  r  y  blood- 
pressure  reading. 


108 


BLOOD-PRESSXJRE 


where  it  is  secured  in  position  by  a  narrow  metallic  spring 
band  similar  to  a  phone  operator's  head-band.  It  is  thus 
self-retaining  and  allows  the  operator  the  freedom  of  both 
hands    with    which    to   manage   the   sphygmomanometer. 

This  is  quite  impor- 
tant, as  it  will  be  found 
expedient  to  note  the 
first  disappearance  of 
the  pulse  by  palpation 
of  the  radial,  as  in  the 
other  methods,  there- 
by preventing  acci- 
dental or  careless  over- 
compression  of  the 
arm. 

Fig.  30  represents  a 
new  device,  first  sug- 
gested by  James  F. 
Prendergast^  which 
facilitates  the  teaching 
of  blood-pressure  read- 
ings by  the  ausculta- 
tory method.  The  multiple  binaurals  permit  anyone 
familiar  with  the  sounds  heard  during  auscultatory  blood- 
pressure  observations  to  direct  the  attention  of  a  small 
group  of  observers  during  the  actual  performance  of 
the  test.  No  difficulty  in  hearing  the  sounds  has  been 
experienced  from  the  greater  distribution  of  the  sound 
through  a  larger  tubular  system. 


Fig.  30. — Multiple  sphygmometroscope. 
Adaptation  of  multiple  by  stethoscope  for 
auscultatory  reading  of  blood-pressure. 


ij.  F.   Prendcrgast,  N.   Y.  Med.  Jour.,  Vol.  xcvii,  No.  2,   1913. 


CHAPTER  VI 

THE  NORMAL  BLOOD-PRESSURE;  ITS  VARIATIONS 

AND  THE  PHYSIOLOGIC  OR  NON-PATHOLOGIC 

FACTORS  AFFECTING  IT 

General  Considerations. — In  any  attempt  to  discuss 
blood-pressure  be  it  the  systolic,  the  diastolic  or  the  pulse 
pressure,  viewed  either  separately  or  combined,  we  are  at 
once  confronted  with  the  question,  what  constitutes  a 
normal  reading,  what  are  its  variations,  and  to  what  are 
they  attributable?  Also,  how  is  the  normal  reading  related 
to  the  clinical  picture  and  when  does  it  transgress  the  recog- 
nized limits  of  normal  and  become  pathologic? 

To  intelligently  and  rationally  apply  the  readings 
obtained  in  blood-pressure  study,  these  questions  must  be 
thoroughly  considered. 

The  clinical  value  of  blood-pressure  studies  is  in  direct 
proportion  to  the  experience  of  the  attending  physician,  for 
only  those  who  regularly  make  blood-pressure  observations 
and  record  the  results  can  hope  to  realize  the  full  benefit  to 
be  derived  from  noting  those  smaller  variations,  which  are 
often  within  normal  limits,  and  whose  value  the  casual 
worker  will  fail  to  appreciate  even  if  he  should  detect  them. 

The  veriest  tyro  will  experience  little  difficulty  in  esti- 
mating the  significance  of  great  variations  in  pressure,  but 
in  such  cases  the  observations  are  merely  corroborative,  as 

109 


110  BLOOD-PRESSURE 

the  general  clinical  picture  will  usually  furnish  the  same 
information  equally  well. 

When  it  comes  to  a  consideration  of  the  variations  in 
systolic,  diastolic  and  pulse  pressures,  and  their  ever- 
changing  relations,  the  problem  becomes  more  complex, 
and  not  infrequently  borders  on  a  field  that  has  been  but 
slightly  explored,  and  in  which  there  is  much  opportunity 
for  further  original  study  and  research. 

At  the  outset  it  must  be  fixed  firmly  in  the  mind  of  the 
reader  that  the  phenomenon  of  blood-pressure  and  its 
manifold  variations  is  most  complex.  The  more  important 
facts  relating  to  this  have  been  considered  in  the  chapter  on 
physiology.  We  find  it  obvious  from  this  study  that 
there  is  no  fixed  normal  pressure  to  serve  as  a  standard,  but 
that  ever-varying  conditions,  both  internal  and  external  to 
the  body,  are  continually  at  work,  and  that  these  result  in  a 
constantly  varying  blood-pressure  picture. 

Instrumental  and  Mechanical  Variations. — Mechanical 
differences  in  instruments,  apart  from  accidental  error,  due 
to  defective  manometers  (which  now  are  rare),  must  be 
considered,  especially  when  comparison  is  made  between 
figures  obtained  some  years  ago  and  now.  In  the  early 
days  of  sphygmomanometry,  the  width  of  the  arm-band, 
and  the  method  of  application  of  pressure  were  not  critically 
considered,  so  that,  except  when  indicated,  it  cannot  be 
determined  whether  figures  refer  to  pressure  tests  made 
with  a  4-,  8-,  12-,  or  16-cm.  cuff,  or  whether  any  cuflf  at  all 
was  used,  as  with  the  early  instruments  of  v.  Basch  and 
Potain. 

All  instruments  employing  the  mercury  scale  or  its 
equivalent  (aneroids  graduated  to  the  mercury  column  in 


THE   NORMAL  BLOOD-PRESSURE  111 

mm.  Hg.)  will  under  the  ordinary  conditions  give  similar 
readings.  The  chief  cause  for  inaccuracy  is  the  use  of 
cuffs  of  varying  width.  The  standard  cuff  as  accepted  by 
most  authorities  is  one  having  a  width  of  compression 
surface  of  4)^  to  5  in.  (11  to  13  cm.)  This,  in  all  but  the 
very  obese  will  give  uniform  pressure  readings,  which  by 
actual  experiment  have  been  found  to  correspond  closely  to 
the  figures  obtained  by  the  direct  introduction  into  a  vessel 
of  a  canula  communicating  with  a  mercury  manometer. 

The  cuff  of  Hiva-Rocci  as  employed  by  Cook,  in  his  sim- 
plification of  the  Riva-Rocci  apparatus,  measures  8  cm.  in 
width.  This  has  been  found  to  interpose  some  resistance 
of  its  own,  due  to  stretching  of  the  rubber  of  the  cuff,  so 
that  readings  obtained  by  it  are  from  6  to  10  mm.  higher 
(depending  on  the  circumference  of  the  arm)  than  those 
obtained  by  the  standard  cuff.  Therefore,  all  figures 
obtained  by  the  narrow  cuff  must  be  corrected,  by  the 
subtraction  of  6,  8  or  10  mm.  before  they  can  be  com- 
pared to  the  standard  reading. 

This  difference  has  been  carefully  figured  out  by  Cham- 
berlain^ and  others  and  is  only  mentioned  in  passing  as  at 
this  late  date  none  but  the  standard  cuff  of  12  mm.  should 
be  employed. 

The  sphygmomanometer  of  Potain  is  not  graduated  in  mil- 
limeters of  Hg.  at  all,  and  therefore  cannot  be  directly  com- 
pared to  the  figures  obtained  by  other  instruments.  Potain 
in  his  work  on  blood-pressure  gives  the  normal  with  his 
instrum.ent  as  150  to  190  for  men  and  140  to  180  for  women. 
The  readings  with  the  Gaertner  tonometer  range  from  10 
to  20  mm.  below  the  standard. 

^Philippine  Jour,  of  Sci.,  December,  1911. 


112  BLOOD-PRESSURE 

THE   NORMAL   BLOOD -PRESSURE 

The  blood-pressure  observation  as  it  is  made  to-day 
includes  an  estimation  of  both  the  systolic  and  diastolic 
pressures  from  which  the  pulse  pressure  is  computed,  and 
any  report  of  blood-pressure  made  within  recent  years 
should  contain  these  figures,  obtained  by  preference  by  the 
auscultatory  method.  This  is  fundamental,  because,  we 
know  now  that  observations  stating  only  the  systolic  pres- 
sure may  be  of  relatively  small  value,  since  they  often  fail 
to  convey  any  information  as  to  the  actual  condition  of  the 
circulation;  indeed  they  may  even  lead  directly  to  an  error 
in  judgment,  since  it  is  not  uncommon  to  meet  cases  in 
which  the  systolic  pressure  appears  to  be  normal,  yet  if  the 
diastolic  and  pulse  pressures  had  been  ascertained,  a  rad- 
ical circulatory  fault  would  have  been  discovered.  On  the 
other  hand,  an  apparently  abnormal  systolic  pressure, 
when  accompanied  by  the  diastolic  observation,  may  show 
to  a  surprising  degree  a  circulatory  efficiency  sustained  by 
relatively  normal  pulse  pressure. 

It  has  already  been  stated  that  blood-pressure  readings 
do  not  represent  absolute  values,  for  we  know  that  all 
observations  must,  to  a  certain  degree  at  least,  be  dis- 
counted, or  better,  be  interpreted  and  adjusted  to  the  whole 
clinical  picture. 

For  convenience  and  for  clinical  study,  certain  rules  have 
been  formulated.  These  are  based  upon  comparative 
clinical  and  experimental  study,  so  that  within  certain  lim- 
its it  is  now  possible  to  state  with  fair  accuracy  the  normal 
average  pressure  readings  for  any  given  age,  together  with 
their  normal  variations.  This  applies  alike  to  systolic, 
diastolic  and  pulse  pressure.     We  may  also  say  in  general 


THE   NORMAL   BLOOD-PRESSURE  113 

that,  under  normal  conditions,  the  diastolic  and  pulse 
pressures,  bear  a  certain  arithmetical  ratio  to  the  systolic 
pressure,  though  even  this  is  variable  and  considerable 
fluctuation  is  compatible  with  health. 

Ignoring  controllable  sources  of  error,  such  as  defective 
apparatus  and  the  personal  equation,  and  adhering  strictly 
to  observations  made  preferably  by  auscultation  with  the 
12-cm.  arm-band,  we  may  down  the  following  rules  for 
guidance  in  estimating  the  degree  of  abnormality  in  blood- 
pressure. 

The  use  of  such  guides  or  rules  appears  essential  to  the 
practical  consideration  of  clinical  cases,  for  without  them 
the  student  or  practitioner,  who  is  unfamiliar  with  the 
employment  of  these  tests,  will  have  great  difficulty  in 
interpreting  pressure  values. 

THE  NORMAL  VARIATIONS  IN  SYSTOLIC,  DIASTOLIC  AND  PULSE 

PRESSURES 

Age. — One  cause  of  alteration  in  blood-pressure,  which 
is  more  or  less  constant  and  progressive  in  nature,  is  that 
incident  to  increasing  years,  and  is  shown  by  a  gradual 
elevation  in  the  average  systolic  and  diastolic  blood-pressure 
in  which  the  diastolic  participates  somewhat  less  than  does 
the  systolic.  The  result  of  this  unequal  change  is  a  grad- 
ual increase  in  pulse  pressure. 

While  innumerable  statistics  are  available  they  are  not  all 
equally  reliable.  Among  the  best  is  the  work  of  Woley,^ 
which  summarizes  a  clinical  study  of  a  thousand  normal 
persons  between  the  ages  of  fifteen  and  sixty  years. 

The  results  are  shown  in  the  chart   (see  Fig.  3)  which 

1  Jour.  A.  M.  A.,  Vol.  Iv,  2,  1910,  p.  121. 


114  BLOOD-PRESSURE 

gives  also  the  general  average  systolic  pressure  for  any 
age  within  these  limits,  also  the  average  high  and  low 
pressures,  together  with  the  average  for  males  and  for 
females  at  all  ages.  Except  for  slight  and  inconsequent 
differences,  these  figures  are  in  close  accord  with  those  of 
other  recent  investigators. 

There  are  a  few  points  worthy  of  notice  that  might  be 
mentioned  here,  namely,  in  regard  to  a  rapid  or  slow  pulse.* 
The  average  blood-pressure  in  all  cases  with  a  pulse  under 
65  was  123  mm.,  while  the  average  blood-pressure  in  all 
cases  with  the  pulse  over  85  was  130  mm.  It  was  also 
noticed  that  there  were  twice  as  many  healthy  individuals 
with  a  pulse  over  85  as  there  were  with  a  pulse  under  65. 

In  my  recent  teaching  on  this  subject,  it  has  been  my 
habit  to  state  that  the  average  systolic  pressure  for  males  of 
twenty  years  is  120  mm.  Hg.,  and  to  suggest  the  employ- 
ment of  a  formula  devised  to  give  approximately  the  aver- 
age systolic  reading  for  any  age,  as  affected  by  that  factor.^ 

The  only  change  since  made  has  been  that  of  phraseology 
which  now  eliminates  fractions.  In  these  six  years  I  have 
found  no  reason  to  alter  the  formula  which  has  been  adopted 
in  many  many  directions  including  some  of  our  larger 
insurance  companies.  The  formula  is  as  follows:  ''Con- 
sider the  normal  average  systolic  pressure  at  age  twenty  to 
be  120  mm.  Hg.,  then  add  1  mm.  Hg.  for  each  additional 
two  years  of  life  over  age  twenty."  Of  course  it  is  realized 
that  figures  obtained  by  this  or  any  other  arbitrary  formula 
must  be  endowed  with  great  elasticity,  and  must  at  times 

^  Woley,  loc.  cit. 

2  "The  Sphygmomanometer  and  Its  Practical  Application,"  1st  edition, 
1909,  The  G.  P.  Pilling  &  Son  Co.,  Philadelphia. 


THE   NORMAL  BLOOD-PRESSURB  115 

be  so  modified  by  so-called  physiologic  factors  as  to  lose 
entirely  this  relation. 

The  Systolic  Pressure  in  Childhood. — There  is  a  certain 
definite  relation  between  the  age  of  the  child  and  the  height 
of  pressure.  The  younger  the  child  the  lower  the  pressure, 
yet  the  tallness  of  the  child  often  has  a  greater  bearing  on 
the  systolic  pressure  than  has  the  body  weight.  Sex  plays 
but  an  insignificant  part,  as  we  but  seldom  meet  differences 
of  more  than  5  mm.  attributable  to  the  sex  factor. 

The  blood-pressure  in  children  will  be  found  to  vary  under 
the  same  conditions  and  influences  that  operate  in  the  adult 
except  that  the  physical  development  factor  is  often  more 
powerful  in  proportion.  The  actual  difference  in  pressure 
readings  made  at  different  times  will  not  be  as  great  as  in 
adults  on  account  of  the  relatively  lower  systolic  pressure. 

The  diastolic  pressure  is  usually  between  25  and  35  mm. 
below  the  systolic,  which  means  that  the  pulse  pressure  is 
between  25  and  35  mm. 

My  own  observations  lead  me  to  believe  that  puberty  in  a 
normal  well-nourished  child,  is  the  beginning  of  the  estab- 
lished adult  pressures  as  found  in  the  adult.  I  have  often 
met  pressures  of  S.  110-D.  80-  PP.  30  in  children  of  from 
fifteen  to  seventeen  years  of  age.  The  following  composite 
table  will  give  a  fair  indication  of  the  average  systolic  pres- 
sures between  the  ages  of  one  and  seventeen  years. 

Systolic  pressures  in  millimeters  of  mercury  (9-cm.  or 
12-cm.  arm-band,  depending  on  size  of  arm). 

Age  Mm.  Hg.  Age  Mm.  Hg. 

Up  to  1  year 70-85  Up  to  10  years 90-105 

Up  to  2  years 75-90  Up  to  13  years 95-110 

Up  to  4  years 80-95  Up  to  15  years 95-115 

Up  to  6  years 80-100  Up  to  17  years 95-120 


116  BLOOD-PRESSURE 

The  averages  as  obtained  in  my  own  observations,  while  not 
in  absolute  accord  with  this  table  or  with  other  individual 
reports,  are  no  more  at  variance  than  those  of  other 
reporters. 

It  will  be  found  extremely  difficult  to  make  accurate 
records  in  children  under  three  years  of  age,  even  of  the 
systolic  pressure  alone,  while  to  determine  the  diastolic  is 
at  times  impossible. 

In  children  except  in  extreme  conditions  the  diastolic 
pressure  is  of  little  importance,  as  this  observation  attains 
its  greatest  value  in  chronic  and  constitutional  diseases 
which  are  rarely  met  in  early  life. 

Diastolic  Pressure  in  Adults. — Until  recently  the  study 
of  the  diastolic  pressure  received  but  a  fraction  of  the  atten- 
tion which  it  deserves,  because  of  the  unreliability  of  the 
readings,  this  being  the  result  of  the  great  variety  of 
methods  heretofore  employed  in  blood-pressure  studies  and 
also  because  of  the  scarcity  of  reports  of  sufficiently  large 
series  of  diastolic  observations  from  which  to  obtain  reliable 
averages.  From  the  study  of  a  large  number  of  observations 
which  I  have  recorded,  in  which  the  auscultatory  method 
alone  was  used,  I  have  reached  the  conclusion  that  a  work- 
ing formula  may  be  safely  employed,  if  not  applied  too 
rigidly,  which  will  give  an  approximate  indication  of  the 
normal  diastolic  pressure  in  relation  to  any  given  systolic 
pressure  in  health,  and  that  it  can  be  used  as  a  guide  to 
separate  the  normal  from  the  pathologic  blood-pressure 
values.  Briefly  stated  this  formula  is  as  follows:  ''The 
diastolic  pressure  will  appropriate  in  value  two-thirds  of 
the  systolic  pressure  and  the  pulse  pressure  will  be  one-third 
of  the  systolic  pressure  or  one-half  of  the  diastolic  pressure." 


THE   NORMAL  BLOOD-PRESSURE 


117 


This  gives  a  systolic,  diastolic  and  pulse  pressure  ratio  of 
3:2:1. 

Again  let  me  reiterate  that  these  values  are  not  absolute 
and  should  not  be  so  considered.     They  must  often  be 


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Fig.  31. — Shows  a  series  of  blood  pressure  readings  in  twenty  normal 
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a  pulse  pressure  of  43  mm.  Hg. 


much  modified,  to  meet  those  many  non-pathological 
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Fio.  32. — For  explanatory  note,  sec  following  page. 


THE   NORMAL  BLOOD-PRESSURE  119 

For  illustrative  purposes,  in  a  paper  appearing  in  the 
New  York  Medical  Journal  (Feb.  27,  1915)  I  selected  at 
random  twenty  complete  observations  made  upon  twenty- 
normal  individuals  between  the  ages  of  twenty-two  and 
jSfty-three.  These  cases  were  all  in  good  health,  but  in  this 
series  no  particular  effort  was  made  to  exclude  the  usual 
normal  causes  of  variation  (see  Fig.  31).  By  consulting 
this  table,  we  find  the  highest  systolic  pressure  was  155, 
the  lowest  110.  The  lowest  diastolic  pressure  70,  and 
the  highest  100.  The  greatest  pulse  pressure  was  55 
and  the  smallest  35.  The  average  figures  for  the  twenty 
cases  were  systolic  pressiu-e  125,  diastolic  pressure  85, 
pulse  pressure  43  (excluding  fractions)  which  conforms 
almost  exactly  to  the  3:2:1  ratio  (for  comparison  with 
abnormal  series,  see  chart  (Fig.  32). 

Sex. — The  average  systolic  pressure  for  women  in  a 
series  of  2000  observations  recorded  by  Theodore  C.  Jane- 
way,  was  10  mm.  less  than  that  of  males.  In  children 
this  variation  rarely  exceeds  5  mm.     The  diastolic  pres- 

FiG.  32.' — Represents  a  series  of  blood-pressure  readings  in  twenty 
abnormal  individuals.  In  each  case  the  initial  observation  was  used, 
in  order  that  it  might  not  be  influenced  by  therapeutic  measures,  but 
would  represent  the  state  of  the  circulation  resulting  from  the  pathological 
condition.  Much  interesting  information  may  be  derived  from  a  comparison 
of  the  two  charts,  the  more  important  points  of  which  are  discussed  below. 

1,  L  C,  age  23,  m.,  double  aortic.  2,  E.  F.,  age  71,  f.,  mitral  regurgitation.  3,  C.  H. 
W.,  age  62,  f.,  angina  pectoris?  4,  Edwards,  age  74,  f.,  chronic  myocarditis.  6,  J.  A.,  age 
58,  f.,  myocarditis,  chronic.  6.  R.  McC,  age  50,  f.  pyorrhoea,  autointox.  7,  W.  M.,  age 
69,  m.,  Chr.  interstitial  N.  8,  A.  J.,  age  63,  m.,  arteriosclerosis.  9,  B.  M.  McG.,  age  64, 
m.,  Chr.  myocarditis.  10,  Dr.  M.,  age  69,  m.,  arteriosclerosis.  11,  W.  B.,  age  65,  m., 
arteriosclerosis.  12,  E.  W.  C,  age  54,  m,  cardiovascular.  13,  J.  F.,  age  55,  f.,  chronio 
myocarditis.  14,  R.,  age  60,  f.,  myocarditis,  chronic.  15,  E.  S.  T.,  age  67,  m.,  arterio- 
sclerosis. 16,  M.  J.  S.,  age  36,  m.,  acute  nephritis.  17.  F.  M.  R.  age  46,  m.,  chronio 
interstitial.  18,  S.  F.  R.,  age  42,  m.,  arteriosclerosis.  19,  C.  B.  Y.,  age  60,  m.,  cardio- 
vascular.   20,  S,  age  52,  m.,  arteriosclerosis. 

'Solid  black  line  represents  systolic  pressure,  broken  black  line  represents  diastolic  pres- 
sure, line  of  dots  and  dashes  represents  the  pulse  pressure,  and  solid  line  with  crosses 
represents  pulse  rate. 


120 


BLOOlJ-PRESSURE 


sure  is  relatively  higher  in  women  for  the  same  age,  due 
chiefly  to  their  generally  poorer  muscular  development; 
as  a  result,  the  pulse  pressure  averages  about  5  mm.  less 
in  women  than  in  men. 

Size,  Muscular  Development  and  Body  Strength. — The 
physical  fitness  and  muscular  development  of  the  in- 
dividual affects  slightly  the  average  normal  blood-pressure 
readings.  It  has  already  been  stated  that,  because  of 
generally  poorer  muscular  development,  the  systolic  pres- 
sure in  women  is  lower  than  in  men.     A  difference  may 


Fig.  33. — Chart  showing  averages  of  blood-pressure  at  different  age 
periods.  The  line  A-A  indicates  a  higher  than  average  blood-pressure  in 
trained  athletes  (Barach  and  Marks). 


also  be  noted  between  the  average  pressure  in  men  of 
poor,  as  compared  with  those  of  robust,  physique;  as  for 
example,  between  the  sedentary  clerk  and  the  trained 
athlete.  A  difference  of  from  10  ta  15  mm.  in  the  systolic 
pressure  and  a  proportionate  variation  in  the  diastolic 
and  pulse  pressure  may  thus  be  accounted  for. 

A  recent  study  by  Barach  and  Marks ^  throws  some 
light  upon  the  subject  of  absolute  strength  in  comparison 
with  the  average  systolic  pressure.     This  work  was  per- 

»  Joseph  H.  Barach  and  W.  L.  Marks,  Arch.  hit.  Med.,  May,  1913,  No.  2, 
p.  485. 


THE   NORMAL  BLOOD-PRESSURE  121 

formed  on  forty-eight  students  between  the  ages  of  fifteen 
and  thirty,  with  the  following  results: 

Average  Systolic  Pressure  as  Compared  with  Strength. 
— Total  strength  (intercollegiate  standard)  range  between 
704  and  541  kilo.  Average  systolic  standing  was  124.5 
mm.  Average  diastolic  79.35.  Pulse  pressure  44.91. 
Total  strength  between  505.4  and  355.9  kilo,  average 
systolic  pressure  120.57,  average  diastolic  74.61,  average 
pulse  pressure  45.96  (see  Fig.  33). 

There  is  seldom  any  appreciable  variation  between  the 
pressure  readings  in  the  two  arms,  except  in  cases  too  rare 
to  be  considered,  neither  does  the  muscular  development 
of  the  arm  or  the  size  of  the  part  have  any  influence  on  the 
blood-pressure  reading,  although  an  extremely  large  arm 
with  a  too  narrow  band  may  give  readings  which,  due  to 
these  elements  of  error,  are  too  high.  The  same  may  be 
said  of  pressure  readings,  made  upon  a  part  that  is  the 
seat  of  edema. 

Temperature,  Emotion  and  Excitement. — The  statement 
of  certain  observers  to  the  contrary,  it  seems  very  unrea- 
sonable and  hardly  likely  that  the  temperamental  charac- 
teristics of  an  individual  can  produce  any  permanent 
variation  in  the  average  pressure  level;  for  example  we 
detect  no  appreciable  difference  in  the  average  readings  in 
the  nervous  as  compared  with  the  phlegmatic  type. 

There  is  no  doubt,  however,  regarding  the  marked 
influence  of  temperament  upon  the  degree  of  response  to 
external  stimuli,  both  physical  and  psychic;  thus  the 
nervous  high-strung  individual  will  show  a  greater  re- 
sponse to  excitement  as  shown  by  a  transitory  rise  in 
blood-pressure  than  will  the  placid  individual.     Judson 


122 


BLOOD-PRESSURE 


Daland/  cites  a  case  of  a  person  driving  an  automobile 
through  a  crowded  thoroughfare  with  a  resulting  rise  of 
20  mm.  in  the  systolic  and  15  in  the  diastolic  whereas  the 
same  individual  driving  through  a  quiet  street  experienced 

a  rise  of  but  15  in  the  systolic. 

The  disturbing  influence  of 
nervous  excitability  is  fre- 
quently met  while  endeavoring 
to  ascertain  the  true  pressure 
levels  in  nervous  and  high- 
strung  persons.  In  interpreting 
pressure  readings  made  when  it 
is  plainly  impossible  to  elimi- 
nate this  psychic  influence, 
allowance  must  be  made  for 
discrepancies  of  this  origin,  par- 
ticularly when  such  readings 
show  abnormal  variations 
within  a  limited  space  of  time 
(see  Fig.  34). 

Severe  pain  may  increase  the 
systolic  pressure  from  15  to  25 
mm.  Mental  excitement  and 
anger  may  cause  an  even 
greater  rise. 

The  effects  of  excitement,  apprehension  and  fear  are  seen 
repeatedly  in  daily  practice,  where  the  initial  reading  may 
be  surprisingly  high,  while  later  readings,  as  the  patient 
becomes  accustomed  to  the  procedure,  are  found  to  main- 
tain a  lower  level  (see  page  355). 

^  Penna.  Med.  Jour.,  July,  1913. 


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Fia.  34. — Rapid  variation  in 
systolic  blood-pressure,  occur- 
ring in  forty-five  minutes,  pa- 
tient sitting  quietly  in  ofRce. 


THE   NORMAL  BLOOD-PRESSURE 


123 


In  such  cases,  much  may  be  done  to  ehminate  these 
factors  by  estabhshing  cordial  relations  between  the  patient 
and  the  operator,  and  by  carefully  explaining  the  technique 
of  the  observation  and  the  amount  of  discomfort  to  be 
expected. 

Posture. — 0.  Z.  Stevens^  reports  a  series  of  obser- 
vations upon  twenty  healthy  medical  students,  in  which 
the  systolic  pressure  and  pulse  rate  alone  were  studied 
in  all  conceivable  postures. 


Ten  Centimeter  Cuff.     Pressure  in  Millimeters  of  Mercury 

Systolic  Pressure  and  Pulse  Rate^ 


Systolic  pressure 


Standing 


Sitting 


Supine 


Head 
down 


Right 
lateral 


Left 
lateral 


Right  arm 
Average . . 
Left  arm. . 
Pulse  rate 


132.6 

130.8 

130.0 

86.0 


133.3 
131.7 
130.0 

82.0 


152.5 
150.4 
148.3 

68.7 


166.2 

165.6 

165.0 

65.8 


155.0 

143.5 
141.0 

68.1 


110.0 

133.0 

156.0 

69.1 


An  extensive  experimental  study  already  referred  to' 
covers  the  effect  of  change  in  posture,  without  physical 
exertion,  upon  the  pressure,  from  which  article  the  ac- 
companying table  is  taken. 

Summary. — In  changing  from  the  erect  to  the  horizontal, 
the  systolic  pressure  will  usually  be  increased.  The 
diastolic  pressure  will  almost  always  be  diminished.  When 
the  erect  posture  is  resumed,  the  systolic  pressure  will 
almost  invariably  fall  and  the  diastolic  rise. 


^loc.  cit. 

8  O.  Z.  Stephens,  Jour.  A.  M.  A.,  Oct.  1,  1904. 

^  Barach  and  Marks,  loc.  cit. 


124 


BLOOD-PRESSUBE 


Effects  of  Changes  of  Posture  on  Arterial  Pressure. — {Barach  and  Marks) 
Subject  at  Rest  on  a  Movable  Table 


Masimal  pressure 

Than 
first. 

Minimal  pressure 

Than 

Erect 

Horizontal 

Erect 

Erect; 

Horizontal       Erect 

first 

X 

28  + 
20- 

7  + 
40- 

8  + 
38- 

X 

4+           43  + 
44-          4- 

25  + 
21- 

First      column:  X  =  height  of  maximum  pressure  in  erect. 

Second  column:  +  =  increase  of  maximum  pressure  when  changed  to 
horizontal. 

Second  column:  —  =  fall  of  maximum  pressure  when  changed  to  hori- 
zontal. 

fall  of  maximum  pressure  when  changed  to  erect, 
rise  of  maximum  pressure  when  changed  to  erect, 
the  height  of  maximum  pressure  was  lower  when 
the  erect  posture  was  resumed,  than  the  first  read- 
ings in  the  erect, 
height  of  maximum  pressure  greater  than  first. 


Third  column:  — 
Third  column:  + 
Fourth  column:  — 


Fourth  column:  + 

Pulse  Pressures. — These  range  between  15  and  72,  the 
average  being  36.46,  being  greater  when  the  maximum 
pressure  is  higher.  Arranged  according  to  age,  in  the 
erect  posture  it  was  37.1  between  ages  sixteen  and  twenty- 
one,  and  40.61  between  ages  twenty-one  and  thirty. 

Effect  of  Change  of  Posture  on  Pulse  Pressure. — From 
erect  to  horizontal  an  increase  in  40  and  a  fall  in  7.  From 
horizontal  to  erect  a  decrease  in  41  and  increase  in  4. 
Finally,  it  remained  higher  than  the  first  reading  in  eleven 
cases.  The  pulse  pressure  seems  to  vary  in  the  same 
direction  as  the  maximum  pressure. 

When  considering  the  effect  of  posture  upon  blood- 
pressure  readings  one  should  not  confound  this  with  the 
efifect  of  gravity  upon  the  fluid  in  the  arterial  tree,  which 
is  the  same  as  might  be  expected  in  any  problem  in  hydro- 
statics.    This  source  of  error  may  be  eliminated  by  keep- 


THE   NORMAL  BLOOD-PRESSURE  125 

ing  the  arm  in  such  a  position  that  the  cuff  is  always 
approximately  at  the  heart-level,  irrespective  of  the  posi- 
tion of  the  patient,  and  also  by  making  all  subsequent 
observations  on  the  same  patient,  in  the  same  posture  and 
under  the  same  condition  as  far  as  practicable. 

Sleep  and  Rest. — Prolonged  rest  in  bed  for  one  pre- 
viously active,  especially  if  there  be  a  tendency  to  high 
pressure,  will  result  in  a  rapid  and  sometimes  in  a  marked 
fall  in  systolic  pressure,  with  a  production  of  a  new  and 
lower  systolic  level.  Brooks  and  CarrolP  do  not  believe 
that  physical  rest  alone,  either  in  normal  or  in  high- 
pressure  cases,  is  responsible  for  this  effect  upon  the 
systolic  pressure  but  rather  that  the  result  is  due  to  the 
psychic  and  mental  rest  accompanying  the  physical,  and 
that  these  factors  are  accountable  for  the  undoubted 
benefit  derived  from  absolute  rest  in  high-pressure  cases. 
While  the  effect  of  sleep  is  well  known  to  cause  a  marked 
fall  in  systolic  pressure  {vide  infra)  these  investigations 
have  proved  that  the  total  average  twenty-four  hours 
systolic  pressure  shows  little  variation  whether  the  patient 
be  confined  to  bed  or  not.  For  this  reason  they  do  not 
believe  that  the  so-called  "sleep  drop"  can  be  used  thera- 
peutically in  order  to  lower  blood-pressure. 

In  the  examination  of  normal  individuals  (twenty-nine 
with  high  and  thirty  with  low  blood-pressures)  they  found 
that  the  greatest  sleep  drop  occurred  during  the  early 
hours  amounting  to  as  much  as  24  mm.  and  that  three 
hours  after  an  awakening  there  was  still  an  average 
depression  of  12  mm.  The  greatest  fall  occurred  in  those 
having  the  highest  initial  pressure. 

1  Arch.   Int.   Med.,   August,    1914. 


126  BLOOD-PRESSURE 

Disturbance  of  sleep  during  the  first  hours  often  delayed 
but  did  not  necessarily  prevent  the  maximum  fall,  although 
frequent  interruptions  were  likely  to  prevent  it. 

The  relation  of  diastolic  and  pulse  pressure  to  sleep  and 
rest  has  not  been  studied  sufficiently  to  warrant  con- 
clusions, but  owing  to  the  general  vasomotor  relaxation 
which  accompanies  profound  sleep  it  is  probable  that 
the  diastolic  pressure  falls  proportionately  more  (not  in 
actual  millimeters)  so  that  the  pulse  pressure  is  relatively 
larger  during  the  early  hours  of  the  sleep  than  in  the 
daytime. 

Diurnal  Variations. — In  close  relation  to  the  preceding, 
but  not  definitely  a  part  of  it,  are  the  changes  in  pressure 
which  occur  during  the  waking  hours,  incident  to  ever- 
present  and  constantly  varying  physiologic  factors. 

Commencing  with  a  depression  of  10  or  12  mm.,  below 
the  average  systolic,  found  in  the  early  morning  hours,  the 
pressure  gradually  rises  and  reaches  a  maximum  usually 
between  3  and  7  P.M.  This  rise  is  held  to  be  independent 
of  the  effect  of  food  and  of  the  digestive  processes. 
Erlanger  and  Hooker^  have  found  that  the  rise  in  systolic 
pressure  is  greater  than  the  diastolic  rise,  resulting  in  a 
gradually  increasing  pulse  pressure  as  the  day  advances. 
The  range  of  maximum  pressure  varies  considerably  in 
different  individuals,  but  according  to  Weysse  and  Lutz^ 
the  highest  and  lowest  maximum  pressures  are  practically 
equidistant  from  the  average  pressure  of  any  one  individual. 

The  influence  of  the  non-pathologic  or  physiologic  factors 


^  Johns  Hopkins  Hos.  Rep.,  1904,  Vol.  xii,  No.  53. 
«  A.  W.  Weysse  and  B.  R.  Lutz,  Am.  Jour.  Physiol.,  May,  1915,  xxxvii, 
No.  2. 


THE   NORMAL  BLOOD-PRESSURE 


127 


may  so  influence  a  day's  series  of  observations  that  they 
may  not  follow  the  usual  rule.  An  example  of  this  is 
shown  in  Fig.  35.  Physical  and  mental  strain,  the  in- 
gestion of  food  and  fluids  will  produce  striking  and  rather 
rapid  alterations  (see  page  132).  Janeway  has  reported^ 
daily  systolic  variations  amount- 
ing to  60  mm.,  although  per- 
sonally I  have  seen  none  to 
equal  this. 

Periodic  Variations. — The 
daily  pressure  curve  is  subject 
to  intrinsic  variations  of  a  more 
or  less  automatic  character. 
Thus  the  respiratory  move- 
ments may  be  demonstrated  in 
graphic  tracings.  During  quiet 
respirations  these  may  be  so 
slight  as  to  pass  unnoticed, 
although  at  times  violent  respi- 
ratory movements  may  inter- 
fere with  the  accurate  determi- 
nation of  the  systolic  point  by 
auscultation.      The    maximum 

variations  which  may  be  attributed  to  this  factor  rarely 
amount  to  more  than  between  5  and  10  mm. 

It  is  found  that  the  highest  point  of  the  respiratory  curve 
occurs  at  a  point  midway  between  expiration  and  in- 
spiration. The  Traube-Herring  waves,  which  have  been 
attributed  to  chemical  changes  occurring  in  the  blood, 
occur    rhythmically    at    intervals    of    a    few    minutes. 

1  Theodore  C.  Janeway,  "The  Clinical  Study  of  Blood-Pressure,"  1904. 


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Fig.  35. — Record  of  systolic 
pressure  variations  occurring 
during  the  working  hours  of  a 
young  healthy  man. 


128  BLOOD-PRESSURE 

These  variations  are  more  of  academic  than  of  cHnical 
interest. 

Physical  Exercise  and  Exertion. — Exercise  results,  in 
the  normal  individual,  in  an  elevation  in  the  systolic 
blood-pressure,  a  less  proportionate  rise  in  the  diastolic 
pressure  with  a  consequent  increase  in  the  pulse  pressure 
and  an  acceleration  in  heart  rate.^ 

Exhaustive  studies  have  been  made  to  determine  the 
amount  of  actual  energy  expended  as  measured  by  an 
ergostat,  as  compared  with  the  measured  changes  in  the 
blood-pressure,  although  so  far  nothing  of  clinical  value 
has  been  published. 

When  exercise  is  moderate  and  prolonged,  as  in  walking, 
the  systolic  pressure  will  rise  from  5  to  15  mm.  when  it 
appears  to  become  adjusted  to  a  new  level,  upon  which  addi- 
tional exertion  of  the  same  kind  has  little  if  any  further 
effect,  until  a  condition  of  extreme  fatigue  is  reached. 
Fatigue  from  prolonged  muscular  effort  results  in  a  fall 
in  systolic  pressure  which  is  not  immediately  arrested 
by  stopping  the  exertion  but  which  may  progress  until  a 
dangerous  reduction  ensues. - 

The  degree  of  muscular  exertion  and  the  suddenness  of 
the  effort  affects  the  rapidity  and  the  degree  of  systolic 
rise.  Sudden  severe  exertion  has  been  shown  to  cause  a 
systolic  rise  of  50  mm.,  while  severe  exertion  causes  an 
average  rise  of  from  25  to  30  mm.  It  is  also  said  that 
the  degree  of  mental  effort  accompanying  the  physical 
exertion  influences  this  rise,  and  that  it  is  further  in- 
creased by  the  mental  effort.     When  exercise  ceases  (if 

1  Krehl  "Clinical  Pathology,"  1905,  3d  edition, 
*  Karrenstein,  Zeits.  f.  klin.  Med.,  1903,  i,  p.  322. 


THE    NORMAL  BLOOD-PKESSURE  129 

stopped  short  of  fatigue)  the  pressure  rapidly  regains  its 
normal  level  as  does  also  the  pulse  rate. 

Edward  O.  Otis,  from  a  study  of  a  large  number  of 
athletes,  believes  that  a  persistent  fall  in  pressure  following 
prolonged  and  violent  exertion  is  evidence  that  the  exertion 
has  been  too  great  or  too  prolonged.  In  this  same  con- 
nection O.  S.  Lowsley,^  also  studying  healthy  athletes  in 
training,  found  that  the  systolic  pressure  and  the  pulse 
rate  were  usually  increased  during  exertion  and  were 
found  to  be  above  the  original  figures  even  at  the  end  of 
periods  of  prolonged  and  exhaustive  work,  provided  the 
observations  could  be  made  before  the  subsequent  fall 
set  in.  After  the  cessation  of  exercise  there  is  usually  a 
period  of  subnormal  pressure,  and  the  more  exhausting  the 
work  and  the  more  prolonged  the  effort  the  more  marked 
and  prolonged  the  subnormal  phase. 

There  is  often  observed  a  secondary  rise  in  pulse  rate 
during  the  period  of  subnormal  pressure,  the  significance  of 
which  has  not  yet  been  fully  determined. 

Very  violent  exercise  even  for  a  few  seconds,  as  in  a  100- 
yard  dash,  may  cause  a  more  prolonged  and  profound 
subnormal  phase,  than  does  more  prolonged  but  more 
moderate  work. 

Lowsley  suggests  that  the  duration  of  the  subnormal 
phase  may  be  taken  as  a  fair  index  of  the  strain  on  the 
circulatory  system,  and  states  that  he  has  been  led  to  be- 
lieve that  if  the  subnormal  phase  lasts  less  than  an  hour, 
it  may  be  considered  to  be  within  the  hygienic  limit,  but 
that  if  it  persists  for  more  than  two  hours  it  is  a  sign 
that  the  margin  of  safety  has  been  exceeded. 

^  Amer.  Jour.  Physiol.,  Mar.  1,   1911. 


130  BLOOD-PRESSURE 

Passive  Movements  and  Massage. — Passive  movements, 
performed  either  by  attendants  or  by  special  machinery 
devised  for  performing  such  work,  cause  no  significant 
rise  in  blood-pressure;  on  the  contrary,  in  high-pressure 
cases,  they  may  be  relied  upon  to  reduce  the  pressure. 
The  effect  of  such  measures  on  diastolic  and  pulse  pressure 
has  not  been  sufficiently  studied  to  base  reliable  con- 
clusions upon. 

Massage  even  when  applied  over  the  abdomen  has  not 
been  shown  to  cause  an  appreciable  rise  in  systolic  pressure* 
(see  also  page  441). 

Altitude  and  Atmospheric  Pressure. — B.  P.  Pomeroy- 
states  that  nearly  all  clinical  and  experimental  data  show 
that  a  reduction  of  barometric  pressure  causes  a  lowering 
of  both  systolic  and  diastolic  blood-pressure  and  that 
this  effect  is  not  transient  but  persists  during  the  con- 
tinuance of  the  low  barometer.  The  reduction  in  pressure 
is  usually  accompanied  by  a  slight  rise  in  pulse  rate.  F.  C. 
Smith,  ^  from  studies  of  250  normal  individuals  at  an 
altitude  of  6000  ft.,  as  compared  with  the  reports  of 
studies  by  competent  observers  made  at  sea  level,  believes 
that  the  effect  of  altitude  and  barometric  pressure  is 
overestimated,  and  sometimes  confused  with  that  of 
other  influences;  nevertheless,  the  average  fall  reported 
by  other  observers  taken  after  the  sharp  variation,  due 
to  sudden  change  have  been  compensated,  while  present 
rarely  exceeds  10  mm.  Bearing  on  the  same  subject,  is 
H.  Brooks'^  study  of  the  blood-pressure  of  seventy-five 

lEichberg,  Jour.  A.  M.  A.,  Sept.  19,  1908. 
'^Jnt.  Med.  Jour.,  Vol.  xviii,  1911,  p.  731. 
^Jour.  A.  M.  A.,  May  29,  1915,  Vol.  Ixiv,  No.  22. 
*  Med.  Rec,  May  25,  1907. 


THE    NORMAL   BLOOD-PRESSURE  131 

compressed-air  workers  before,  during  and  after  working 
in  caissoris.  He  found  a  rise  in  arterial  pressure  while 
working  under  compressed  air  (-f  31  lb.)  but  noted  that  the 
variation  in  systolic  pressure  afterward,  was  no  greater 
than  that  found  under  usual  atmospheric  conditions, 
neither  was  the  pulse  pressure  altered;  therefore  moderate 
degrees  of  heart  and  kidney  disease  are  not  contra-indi- 
cations  to  working  under  compressed  air. 

The  Taking  of  Food,  Drink  and  Digestion. — Weysse 
and  Lutz'^  found  that  a  rise  in  systolic  pressure,  averaging 
8  mm.  Hg.  occurs  immediately  after  the  ingestion  of  food. 
This  maximum  elevation  according  to  M.  Loeper,^  persists 
for  from  fifteen  to  forty-five  minutes,  after  which  it  falls 
to  a  point  slightly  below  the  normal,  while  after  the  third 
hour  a  second  elevation  was  regularly  noted.  (Weysse 
and  Lutz  did  not  note  this.)  Loeper  analyzes  the  different 
elements  which  may  be  responsible  for  these  fluctuations. 
Thus  the  initial  hypertension  seems  to  be  due  exclusively 
to  the  distention  of  the  stomach,  and  an  increase  in  intra- 
abdominal pressure,  as  it  is  more  marked  the  larger  the 
amount  eaten  and  drunk.  The  secondary  hypertension 
corresponds  to  the  active  period  of  gastric  secretion  (splanch- 
nic hyperemia)  and  was  found  more  marked  after  foods 
that  stimulate  gastric  secretions,  being  strongest  with  a 
meat-containing  meal,  weakest  with  milk  and  very  transient 
with  water  and  macaroni.  The  secondary  hypertension 
corresponds  to  the  distension  of  the  intestines  and  is 
probably  the  result  of  the  rapid  absorption  of  digestive 
substances,  having  a  directly  hypertensive  action  upon  the 

^  Loc.  cit. 

2  Arch,  des  Maladies  du  coeur,    March,  1913. 


132  BLOOD-PRESSURE 

blood-vessel  walls  or  a  stimulating  effect  upon  the 
chromaffin  system  (author's  conclusion). 

H.  L.  Higgins^  attempts  to  explain  the  effect  of  food  and 
digestion  upon  blood-pressure  by  the  influence  of  these 
processes  upon  alveolar  carbon  dioxide  and  the  effects  of 
such  changes  on  the  respiratory  and  cardiac  centers. 
He  states  that  alveolar  CO2  rises  on  taking  food  and 
remains  high  during  active  digestion,  and  that  a  high 
alveolar  air  content  is  coincident  with  vasodilatation 
while  a  low  alveolar  CO2  tension  causes  vasoconstriction. 

These  facts  would  seem  to  demonstrate  the  advisability 
of  avoiding  large  meals  or  imbibing  much  fluid  in  diseased 
conditions  accompanied  by  high  pressure.  For  the  same 
reason,  stimulating  foods  are  to  be  avoided  especially  by 
those  with  arteriosclerosis  and  chronic  kidney  disease. 

Erlanger  and  Hooker  have  noted  a  constant  increase  in 
pulse  pressure  during  the  active  digestive  process.^ 

The  ingestion  of  a  large  amount  of  fluid,  particularly  of 
beer,  is  usually  followed  by  a  transitory  rise  in  systolic 
pressure,  which  may  amount  to  from  10  to  20  mm. 

Influence  of  Menstruation. — At  the  onset  of  this  phe- 
nomenon there  is  a  fall  in  systolic  pressure  reaching  its 
lowest  level  (a  reduction  of  from  15  to  20  mm.)  at  the  height 
of  the  period;  while  the  normal  level  is  again  attained  three 
or  four  days  after  the  cessation  of  the  flow. 

Effects  of  Changes  in  Intra-abdominal  and  Intrathoracic 
Pressures. — Owing  to  the  close  relation  of  the  abdominal 
and  thoracic  cavities  to  the  larger  blood-containing  areas, 
it  seems  advisable  to  include  a  study  of  changes  of  pressure 

1  Am.  Jour.  Physiol.,  April,   1914,  xxxiv,  No.  1. 

2  Johns  Hopkins  Hos.   Rep.,   190-1,  xii. 


THE   NORMAL  BLOOD-PRESSURE  133 

in  these  regions  and  their  effect  upon  blood-pressure  in 
this  chapter  (see  also  Chapter  XX,  page  356). 

H.  Emerson^  states  that  there  exists  an  intra-abdominal 
pressure  in  the  normal  human  which  is  above  atmospheric 
pressure,  and  that  this  fluctuates  with  the  movements  of 
the  diaphragm,  also  that  anything  which  increases  the  intra- 
abdominal pressure  wall  cause  a  fall  in  general  systoUc 
pressure.  This  is  apparently  due  to  diminished  flow  of 
venous  blood  into  the  vena  cava  with  a  resultant  diminu- 
tion in  the  systolic  output  of  the  left  ventricle. 

J.  A.  Capps-  reports  that  drainage  of  fluid  from  the 
thoracic  or  abdominal  cavities  is,  as  a  rule,  accompanied 
by  a  fall  in  systolic  press.ure,  averaging  32  mm.  and  that  the 
greatest  depression  usually  comes  several  minutes  after 
the  needle  is  withdrawn,  though  it  may  occur  at  any  time 
during  the  procedure.  The  amount  of  fall  seems  to  bear  a 
direct  relation  to  the  quantity  of  fluid  removed  and  to  the 
rapidity  with  which  it  is  withdrawn. 

Occasionally  the  fall  is  very  slight.  In  one  case  following 
the  removal  of  3000  c.c.  of  fluid,  a  fall  of  62  mm.  was 
noted.  The  residual  fall  in  systoUc  pressure  observed  one 
hour  after  the  removal  of  the  fluid  averages  12  mm.,  which 
corresponds  to  the  average  fall  of  10  to  14  mm.  in  intra- 
abdominal pressure  after  tapping. 

A  sudden  and  marked  fall  may  result  in  temporary 
collapse,  due  probably  to  a  sudden  relaxation  of  the 
splanchnic  area.  Such  an  incident  can  be  guarded  against 
by  repeated  blood-pressure  observations  during  tapping, 
and  may  often  be  prevented  by  external  pressure  upon  the 

^  Arch.  Int.  Med.,  June,  1911. 

'^Jour.  A.  M.  A.,  1907,  xlviii,  No.  1. 


134  BLOOD-PBESSURE 

abdominal  wall  which  will  cause  an  immediate  rise  of  5  to 
20  mm.  Hg.  in  systolic  pressm-e. 

Posture  is  important,  as  normally  the  pressure  is  higher  in 
the  sitting  than  in  the  recumbent  posture,  although  at  the 
end  of  paracentesis,  the  mere  fact  of  lying  down  often 
increases  the  systolic  pressure  from  6  to  20  mm. 

Effect  of  Vomiting  on  Blood-pressure. — According  to 
the  experimental  studies  of  Brooks  and  Luckhardt^  vomit- 
ing occasions  marked  changes  in  the  circulatory  system. 
There  is  seen  sometimes  a  period  of  elevated  pressure,  but 
more  frequently,  a  sudden  and  enormous  drop  in  systolic 
pressure  with  cardiac  inhibition,  at  the  moment  of  emesis. 
There  are  always  great  oscillations  in  blood-pressure. 
These  great  and  sudden  variations,  might  cause  a  rupture 
of  blood-vessels  which  would  not  occur  with  the  same 
pressure  but  with  slower  changes. 

1  C.  Brooks  and  A.  B.  Luckhardt,  Am.  Jour.  Physiol.,  January,  1915, 
xxxvi,  No,  2. 


CHAPTER  VII 
THE  PULSE  PRESSURE 

While  the  systolic  pressure  has  been  receiving  great 
attention  from  the  general  practitioner  the  other  phe- 
nomena of  blood-pressure,  the  diastolic  pressure,  and  the 
pulse  pressure,  which  is  the  difference  between  the  systolic 
and  diastolic  pressure  have,  until  quite  recently,  received 
but  scant  attention.  Possibly  this  is  due  to  the  fact  that 
the  methods  of  measuring  the  diastolic  pressure  have  not 
been  uniform  and  thus  no  comparison  was  possible  between 
the  results  of  different  observers,  while  even  those  of  a 
single  observer  were  so  variable  that  no  conclusions  could 
be  drawn. 

It  is  now  accepted  that  the  auscultatory  method  of 
determining  blood-pressure  is  the  most  accurate  and  uni- 
form of  all  the  methods  available  for  bedside  work,  so  the 
early  difficulty  no  longer  exists.  There  appear  to  be  two 
schools  of  teaching  (see  page  90)  regarding  the  method 
of  determining  the  pulse  pressure  by  auscultation,  one 
of  which  teaches  that  the  disappearance  of  all  sound  is  the 
diastolic  point,  the  other  that  the  point  of  transition  from 
the  third  to  the  fourth  phase  (fourth  point  of  Swan)  is 
the  diastolic  point.  The  difference  between  these  two 
methods  is  sufficient,  except  in  the  exceptional  case  when 
the  change  from  fourth  to  fifth  point  is  almost  simultaneous, 

to  alter  to  an   appreciable    degree  the   pulse   pressure. 

135 


136  BLOOD-PRESSURE 

This  difference,  according  to  Swan,^  averages  14  mm., 
being,  of  course,  lower  when  the  fifth  point  is  taken  as 
the  criterion.  Accepting  45  mm.  as  a  fair  average  pulse 
pressure  it  is  evident  that  the  difference  in  reading  resulting 
from  differing  interpretation,  can  amount  to  333^3  per  cent, 
more  of  the  whole.  Throughout  this  work,  unless  other- 
wise specified,  the  data  employed  are  based  upon  diastolic 
readings  made  at  the  fifth  point,  that  is  at  the  moment  of 
disappearance  of  all  sound. 

Concerning  the  importance  of  a  knowledge  of  the  pulse 
pressure,  it  seems  logical  to  believe  that  the  pulse  pressure, 
which  is  the  actual  head  of  pressure  driving  the  blood  into 
the  peripheral  vessels,  and  which  represents  the  systolic 
output  of  the  heart,  should  be  of  first  importance  in  cardiac 
prognosis  (see  functional  tests.  Chapter  XIX,  page  331). 

The  Determination  of  the  Pulse  Pressure. — The  pulse 
pressure  cannot  be  determined  until  both  the  systolic  and 
the  diastohc  pressure  have  been  estimated,  as  it  is  com- 
puted by  subtracting  the  diastolic  pressure  from  the  sys- 
tolic pressure,  and  the  accuracy  with  which  these  are  com- 
puted will  determine  the  accuracy  of  the  pulse  pressure. 
We  believe  the  pulse  pressure  to  be  highly  important 
because  it  is  not  so  much  the  knowledge  of  the  actual 
pressure  (systolic)  under  which  an  organ  receives  its  blood, 
as  it  is  the  knowledge  of  the  amount  of  blood  received  by 
the  organ  per  unit  of  time,  that  enables  us  to  judge  of  func- 
tional capacity.  The  volume  of  blood  delivered  by  the 
heart  to  the  great  vessels  per  minute,  even  if  not  actually 
measured  will  be  indicated  by  the  pulse  pressure,  times  the 
heart  rate  per  minute.     At  the  same  time  this  calculation 

^Loc.  cit. 


THE    PULSE    PRESSURE  13*7 

indicates  the  velocity  of  the  blood,  for  we  believe  that, 
within  certain  fairly  restricted  limits,  there  is  a  relation 
between  pulse  rate,  pulse  pressure  and  blood  velocity,  the 
accuracy  of  this  opinion  has  been  demonstrated,  experi- 
mentally as  well  as  theoretically.^ 

It  has  also  been  shown  that  a  reduction  in  pulse  pressure 
means  a  lessened  velocity  of  blood  flow,  although  the  re* 
verse  is  not  necessarily  true. 

The  Relation  of  Pulse  Pressure  to  Other  Pressure 
Values. — Clinical  evidence  points  clearly  to  the  fact  that 
in  the  normal  adult,  the  pulse  pressure  approximates 
one-third  of  the  systolic  pressure  and  one-half  of  the 
diastolic  pressure,  thereby  giving  a  relation  of  3:2:1  for 
the  systolic,  the  diastolic  and  the  pulse  pressure  (see  chart, 
page  117),  although  slight  variations  from  this  are 
compatible  with  a  normal  cardiovascular  system.  Upon 
the  other  hand,  practically  all  those  conditions  which 
tend  to  an  elevated  systolic  pressure  of  180  or  more  disturb 
this  ratio,  as  do  also  conditions  of  low  pressure,  accom- 
panied by  vasomotor  weakness,  so  that  in  many  chronic 
cardiovascular  and  renal  conditions  and  in  shock,  the 
pulse  pressure  tends  to  approximate  the  diastolic  pressure 
and  may  at  times  equal  or  even  exceed  it  (see  chart, 
page  118).  This  statement  should  not  be  held  invariable, 
as  Warfield^  has  cited  cases  of  myocardial  disease  with 
normal  blood-pressure  values  five  minutes  before  death. 

The  normal  average  pulse  pressure  may  be  considered 
to  lie  between  35  and  50  mm. 

Low  Pulse  Pressure. — The  most  consistent  low   pulse 

1  Louis  M.  Warfield,  Jour.  A.  M.  A.,  Oct.  4,  1913,  Ixi,  14,  p.  1254. 

2  Louis  M.  Warfield,  Amer.  Jour.  Med.  Sci.,  December,  1914,  cxlviii,  6. 


138  BLOOD-PRESSURE 

pressures  are  met  in  cases  of  pulmonary  tuberculosis,  in 
typhoid  fever  between  the  third  and  fifth  weeks,  and  in 
many  wasting  diseases  and  exhausting  fevers.  The  reduc- 
tion of  pulse  pressure  in  these  cases  is  accomplished  chiefly 
at  the  expense  of  the  systolic  pressure,  which  is  reduced 
relatively  more  than  is  the  diastolic  pressure. 

Large  Pulse  Pressure. — According  to  W.  J.  Stone^  the 
pulse  pressure  is  usually  increased  in  anemia.  As  ex- 
amples he  cites  three  cases  in  which  the  systolic  blood- 
pressure  varied  from  120  to  135  and  the  diastolic  pressure 
from  60  to  85,  giving  the  pulse  pressure  45  to  65.  The 
patient  with  the  lowest  red  count  (1,630,000)  had  the 
lowest  diastolic  pressure  and  in  consequence  a  pulse  pres- 
sure of  65.  The  pulse  pressure  in  aortic  insufficiency  is 
always  large,  probably  larger  than  in  any  other  condition 
(see  chart,  page  332). 

In  chronic  nephritis  and  in  arteriosclerosis  with  good 
cardiac  compensation  the  pulse  pressure  is  increased,  while 
in  myocardial  insufficiency  it  varies  depending  apparently 
upon  the  size  of  the  heart,  being  high  where  the  heart  is 
hypertrophied  and  small  whore  the  heart  is  small.  As  a 
general  rule  it  may  be  stated  that  in  general  blood-pressure 
depression,  irrespective  of  whether  the  preceding  pressures 
were  above  normal  or  not,  the  presence  of  a  small  pulse 
pressure  usually  means  a  gravely  affected  heart  and  an 
unfavorable  prognosis. 

Significance  of  Pulse  Pressure  Changes. — In  general, 
when  the  systolic  pressure  is  normal,  an  excessive  pulse 
pressure  signifies  peripheral  dilatation.  When  the  systolic 
pressure  is  high,   the  increased  pulse  pressure  is  to  be 

1  Jour.  A.  M.  A.,  Oct.  4,  1913,  Ixi,  14,  p.  1256. 


THE    PULSE    PRESSURE  139 

regarded  as  normal  and  of  no  special  significance,  es- 
pecially if  the  3:2:1  ratio  is  approximately  maintained. 
Decreased  pulse  pressure  indicates  marked  peripheral 
construction  and  may  be  an  unfavorable  prognostic  sign; 
as  in  disease  conditions  a  decreasing  pulse  pressure  usually 
means  cardiac  failure.  This  condition  often  occurs  in 
the  latter  stages  of  the  high-systolic-increased-pulse 
pressure  cases,  in  which  the  occurrence  of  a  low-systolic 
pressure  and  an  increased  pulse  pressure  usually  means 
circulatory  failure  through  loss  of  vasomotor  tone  and 
heart-muscle  weakness.  This  is  seen  in  febrile  conditions, 
cachectic  states,  malignant  disease  and  in  convalescene 
from  long  illness. 

The  Blood-pressure  Quotient. — It  is  believed  that  the 
pulse  pressure,  divided  by  the  systolic  pressure,  gives  an 
indication  of  the  parts  played  by  vascular  resistance  and 
heart  w^ork  respectively  (see  Functional  Tests,  page  331). 
The  determination  of  the  blood-pressure  quotient  is  based 
upon  the  belief  that  increased  heart  work  is  shown  by 
an  increase  in  systolic  pressure  accompanied  by  an  en- 
larging pulse  pressure,  while  on  the  other  hand  an  in- 
crease in  peripheral  resistance  alone  will  increase  systolic 
pressure  and  decrease  pulse  pressure.  In  addition  reduced 
peripheral  resistance  lowers  systoUc  pressure  and  in- 
creases pulse  pressure;  therefore,  if  the  systolic  pressure 
and  the  pulse  pressure  under  the  same  condition  vary 
proportionately,  that  is,  both  increase,  then  the  cause  lies 
in  the  heart,  while  if  in  reverse  direction  or  if  not  propor- 
tionately, then  the  cause  lies  at  least  in  part  in  changes  in 
vascular  tone.  The  total  cardiac  output  in  a  given  time 
also  bears  a  relation  to  the  number  of  systoles  per  minute. 


140  BLOOD-PRESSURE 

From  these  facts  it  would  seem  safe  to  construct  an  equa- 
tion: Blood-pressure  quotient  =  pulse  pressure  -^  systolic 
pressure  =  normally  about  0.3. 

The  S.  D.  R.  Index  or  Energy  Index. — Barach^  bases 
his  assertions  in  determining  the  energy  index  upon  the 
assumption  that  systole  gives  us  the  energy  factor  in 
the  heart  and  diastole  the  energy  in  the  peripheral  re- 
sistance. From  the  pulse  rate  we  know  how  many  pressure 
impulses  to  each  minute  there  are  in  the  arterial  tree. 
For  example  if  the  systolic  pressure  is  120,  the  diastolic 
pressure  70  and  pulse  rate  72  per  minute,  the  exertion 
in  one  minute  would  be : 

In  systole 120  mm.  Hg.  X  72  =    8,640  mm.  Hg. 

In  diastole 70  mm.  Hg.  X  72  =    5,040  mm.  Hg. 

In  both 190  mm.  Hg.  X  72  =  13,680  mm.  Hg. 

If  the  assumption  of  Barach  is  correct,  it  follows  that 
the  knowledge  of  the  systolic  pressure  alone  gives  but  a 
partial  clue  to  what  is  going  on  in  the  circulation.  In  an 
extensive  series  of  observations  by  Barach  upon  the 
blood-pressure  of  healthy  young  men,  this  contention  seems 
to  be  proved. 

The  conclusion  reached  is  that  the  highest  normal 
energy  index  is  close  to  20,000  mm.  Hg.  per  minute.  In  a 
series  of  ten  cases  of  recognized  cardiovascular  and  renal 
involvement,  five  of  which  afterward  had  apoplectic 
strokes,  the  figures  of  the  total  energy  or  the  S.  D.  R. 
index  were  all  above  20,000,  the  highest  being  50,400. 
Barach  concludes  his  article  by  stating  that  we  may 
obtain  by  this  indication  a  definite  idea  of  the  cardio- 

^Jour.  A.  M.  A.,  1914,  Vol.  Ixii,  7,  p.  525. 


THE    PULSE    PRESSURE  141 

vascular  energy  expanded  and  the  strain  under  which  the 
heart  and  blood-vessels  are  laboring. 

The  Diastolic  Index. — Mac  Williams  and  Melvin^  in 
taking  blood-pressure  observations,  find  it  desirable  to 
determine  what  they  call  the  diastolic  index.  This  is 
based  upon  the  discovery  that  in  certain  cardiovascular 
cases  there  was  a  decided  difference  in  the  diastolic  pressure, 
and  consequently  in  the  pulse  pressure,  when  the  reading 
was  made  on  the  way  up  from  that  made  on  the  way 
down,  and  that  this  finding  gave  valuable  data  as  to  the 
tendency  of  the  case  to  vasomotor  instability.  They 
found  in  some  cases  a  difference  as  great  as  20  mm.  Hg. 
between  the  up  and  down  diastolic  readings. 

1  J.  A.  Mac  Williams  and  G.  S.  Melvin,  Brit.  Med.  Jour.,  Nov.  7,  1914, 
2818. 


^\s> 


/  A 


CHAPTER  VIII 
VENOUS  AND  CAPILLARY  BLOOD-PRESSURE 

While  the  pioneers  in  the  study  of  blood-pressure  did 
not  neglect  the  study  of  capillary  blood-pressure,  they  failed 
to  attach  any  special  importance  to  this  observation, 
probably  because  at  that  time  the  d3aiamics  of  the  circula- 
tion were  but  little  understood  and  also  because  of  these 
crude  methods  for  estimating  capillary  blood-pressure. 

Regarding  the  physiology  of  capillary  blood-pressure,  we 
know  that,  in  comparison  with  the  pressure  within  the 
arterial  tree,  capillary  pressure  is  low,  and  the  flow  uniform 
and  continuous  owing  to  the  length  of  the  conducting  vessels, 
which,  together  with  arterial  elasticity  and  ramification, 
absorb  the  rhythmic  impulses  of  the  heart. 

Conditions  Influencing  Capillary  Pressure. — The  ana- 
tomic situation  of  the  capillaries  places  them  in  a  position 
where  alterations  in  their  pressure,  may  be  affected  by 
both  arterial  and  venous  pressure.  Further,  the  superficial 
location  of  large  areas  of  the  capillaries  subjects  them  to  the 
influence  of  external  agencies. 

A  high  venous  pressure,  by  impeding  the  free  flow  of 
blood  from  the  capillaries  into  the  veins,  will  result  in 
an  increase  in  capillary  pressure.  The  reverse  is  also  true. 
Capillary  pressure  is  influenced  by  the  proximity  of  this 
system  to  the  larger  venous  trunks,  and  again  by  the 
character  of  the  tissues  in  which  the  capillaries  are  located, 

142 


VENOUS    AND    CAPILLAKY   BLOOD-PRESSURE  143 

the  capillary  pressure  being  higher  in  dense  firm  tissues 
than  in  soft  areolar  tissues. 

The  relative  importance  of  capillary  blood-pressure  has 
until  recently  been  rather  underestimated,  although  now 
it  is  receiving  more  deserved  attention,  because  we  more 
fully  realize  the  close  relation  between  the  pressure  in  the 
smallest  arterioles  and  in  the  true  capillaries,  and  the 
maintenance  of  normal  peripheral  resistance  (Chapter  II, 
page  45)  which,  as  has  been  shown,  is  the  prime  factor, 
excepting  the  heart  itself,  in  maintaining  normal  systolic 
and  diastolic  pressure. 

The  actual  pressure  in  the  capillaries  stands  midway 
between  that  of  the  arteries  and  that  of  the  veins,  but  it 
usually  more  closely  approximates  the  venous  than  the 
arterial  pressure. 

Methods  of  Measuring  Capillary  Pressure. — Various 
means  have  been  devised  for  demonstrating  capillary  blood- 
pressure,  the  simplest  being  to  press  upon  a  superficial 
area  with  a  clean  microscope  slide  until  whitening  of  the 
tissues  beneath  occurs.  The  degree  of  pressure  required 
to  accomplish  this  decoloration  will  roughly  measure  the 
capillary  pressure.  Formerly  a  means  of  applying  gradu- 
ated weights  was  employed  to  some  extent,  but  this  has 
been  discarded  as  uncertain  and  unreliable. 

The  most  practical  improvement  in  apparatus  for  the 
measurement  of  capillary  blood-pressure  was  made  by 
Adolf  Easier  and  by  Warren  Lombard^  who  separately 
made  devices  for  this  purpose.  The  instrument  of  Easier, 
the  ''Ochrometer"  appears  to  be  the  most  practical  and 
productive  of  most  accurate  results.     Its  important  features 

^  Zentralbl.f.  Physiol.,  1911,  xxv,  p.  157. 


144  BLOOD-PRESSURE 

briefly  are:  two  small  tin  compartments,  the  tops  of  which 
consist  of  clear  glass  windows,  arranged  for  the  introduction 
of  two  adjacent  fingers  of  the  subject  to  be  tested.  One 
of  the  compartments  contains  a  very  thin-walled  small 
rubber  balloon  which  may  be  so  inflated  that  it  will  subject 
the  finger  to  a  very  delicate  pressure,  which  pressure  is 
measured  in  millimeters  of  mercury.  The  pressure  in  the 
balloon  is  gradually  raised  until  slight  blanching  of  the 
finger  occurs,  this  point  being  the  measure  of  capillary 
blood-pressure.  A  reading  device  composed  of  branching 
tubes  and  prisms  allows  the  two  fingers  to  be  observed 
simultaneously  for  purposes  of  comparison.  This  is  simply 
a  refinement  of  the  older  methods  for  compressing  and 
measuring  the  amount  of  pressure  necessary  to  produce 
change  in  color  in  the  part  under  pressure. 

The  Normal  Capillary  Pressure  and  Its  Modifications. — 
Employing  Basler's  instrument,  Landerer^  found  that  the 
normal  capillary  pressure  varied  between  17  and  25  mm. 
of  mercury,  although  it  may  at  times  rise  as  high  as  70 
(in  firm  tissue  and  branches  of  arterioles).  The  figures 
given  in  the  ''American  Text-book  of  Physiology"  are 
between  24  and  54  mm. 

Landerer  also  made  an  effort  to  itemize  those  diseases  in 
which  the  capillary  pressure  was  either  lowered,  elevated  or 
unchanged.  His  results  were  generally  so  variable  that  they 
possess  very  little  clinical  value,  the  exception  being  in 
cases  of  high  arterial  pressure,  when  he  found  a  more  or  less 
constant  reduction  in  capillary  tension.  This  was  to  be 
expected,  if  we  believe  that  high  arterial  pressure  is  due,  in 
part  at  least,  to  arterial  and  arteriole  tightening  or  narrow- 

'  Rudolph  Landerer,  Zeitsch.  f.  klin.  Med.,  78,  Nos.  1  and  2. 


VENOUS    AND    CAPILLARY   BLOOD-PRESSURE  145 

ing,  which  occurs  only  at  the  expense  of  capillary  blood- 
supply. 

The  application  of  cold  by  reducing  the  bath  temperature 
by  10°  or  15°  C.  diminishes  capillary  pressure;  ^vith  hot 
baths  the  results  may  or  may  not  be  the  reverse. 

This  author  logically  suggests  that  the  condition  of  the 
arterioles  is  far  more  important  in  determining  capillary 
blood-pressure  than  is  the  arterial  pressure;  for,  if  the 
arterioles  are  contracted,  the  capillaries  receive  a  scant 
supply  of  blood  and  the  resulting  pressure  naturally  is 
lowered,  from  which  we  may  conclude  that  the  most 
important  factor  affecting  capillary  blood-pressure  is  the 
condition  of  the  arterioles. 

Federn  takes  the  same  stand,  and  states  that  since  1894 
he  has  been  endeavoring  to  perfect  a  method  which  would 
be  easily  applied,  and  which  would  be  accurate  in  deter- 
mining the  systolic  pressure  in  the  smaller  vessels,  which 
would  be  a  more  accurate  means  of  determining  changes 
in  the  arteriolar  and  capillary  pressures,  than  the  usual 
method  of  compressing  large  trunks.  In  his  ''Optic 
Estimation  of  Blood-pressure"^  he  describes  a  method  of 
measuring  blood-pressure  in  a  small  artery  over  the  tibia, 
and  in  the  superior  anterior  intercostal  artery  by  means 
of  a  von  Basch  compressor  connected  to  a  sphygmoman- 
ometer, the  effect  of  compression  being  shown  by  a  straw 
index  fastened  to  a  disk  of  paper  or  cork  (5.6  mm.  in 
size)  and  pasted  to  the  skin  at  the  point  where  the  pulse 
is  felt.  He  states  that  this  method  eliminates  alterations 
in  pressure  due  to  compression  ischemia  of  a  large  area, 
gives  accurate  readings  and  is  the  best  means  of  estimating 

1  Berl.  klin.  Wochen.,  Mar.  30,  1914,  21,  13. 
10 


146  BLOOD-PRESSURE 

the  functional  capacity  of  the  heart  as  it  gives  an  indication 
of  the  pressure  in  the  capillary  system. 

VENOUS  BLOOD-PRESSURE 

General  Considerations. — Despite  the  close  relation 
which  must  exist  between  the  blood-pressure  in  the  large 
veins  and  the  proper  j&Uing  of  the  auricular  chamber,  and 
through  it  the  capacity  of  the  ventricular  output,  which  is 
the  direct  source  of  arterial  pressure,  there  have  been  but 
few  observations  and  experiments  which  are  sufficiently 
reliable  to  be  depended  upon  for  clinical  deductions. 

Methods  of  Measuring  Venous  Pressure. — The  direct 
canular  method  of  Moritz  and  von  Tabora^  is  undoubtedly 
most  acciu-ate  and,  at  the  hands  of  the  originators,  has 
not  been  followed  by  any  untoward  results.  This  method 
could  be  used  experimentally,  though  it  is  hardly  available 
in  the  consulting  room. 

Other  methods  have  appeared  from  time  to  time  since 
1900,  but  have  failed  of  general  adoption  because  of 
fundamental  errors  in  the  apparatus. 

Two  recent  instruments  (Hooker  and  Eyster,  and  Howell) 
employing  air  as  the  medium  of  pressure,  and  recording 
the  findings  in  centimeters  or  millimeters  of  water,  are 
probably,  at  this  writing,  the  best  instrumental  means  for 
the  measurement  of  venous  pressure. 

The  instrument  of  Hooker  and  Eyster^  is  a  modification 
and  improvement  on  that  of  von  Recklinghausen.  It  is 
composed  of  an  aluminum  form,  shaped  to  fit  the  forearm; 

^  F.  Moritz  and  D.  v.  Tabora,  Deutsch.  Arch.  f.  klin.  Med.,  xcviii,  No. 
4,  p.  475. 

'^  Johns  Hopkins  Hos.  Rep.,  1909,  xix. 


VENOUS    AND    CAPILLARY   BLOOD-PRESSURE  147 

partly  closed  on  the  arm  side  by  a  thin  sheet  of  rubber- 
dam  having  a  central  rectangular  opening,  and  hermetically 
closed  above  by  a  glass  window.  When  applied,  the 
opening  in  the  rubber-dam  is  placed  over  a  large  vein, 
when  by  suitable  means  the  pressure  within  the  chamber  is 
increased  until  the  vein  collapses.  The  amount  of  air 
required  to  accomplish  this  is  measured  in  centimeters  of 
water  by  a  manometer  connected  with  it. 

The  apparatus  of  HowelP  operates  upon  a  different 
principle.  It  employs  two  cups,  each  connected  to  a 
separate  water  manometer.  One  cup  is  applied  to  the 
arm  and  the  other  to  the  forearm,  the  forearm  cup  being 
of  very  thin  rubber.  The  latter  is  inflated  until  it  fits 
snugly  without  exerting  pressure  (not  more  than  1  to  3 
cm.  of  water).  The  upper  cuff  is  then  slowly  inflated  until 
the  manometer  connected  with  the  lower  cuff  shows  a  rise. 
This  rise  shows  compression  of  the  veins  in  the  arms 
and  is  incident  to  an  increase  in  volume  in  the  forearm. 
At  this  moment  the  venous  pressure  reading  is  made.  It 
will  be  noted  that  the  degree  of  pressure  originally  placed 
in  the  lower  cuff  wiU  to  some  extent  affect  the  pressure 
reading,  since  the  higher  the  pressure  over  the  forearm, 
the  higher  will  be  the  venous  pressure  recorded. 

A  simple  method,  ascribed  to  Gartner,  is  described  in 
detail  and  highly  recommended  by  Oliver ^  and  by  Brunton,^ 
for  measuring  variations  in  venous  pressure  without  the 
aid  of  a  sphygmomanometer.  This  method  requires 
nothing  but  a  foot  rule  or  measuring  tape,  the  veins  of  the 

1  A.  A.  Howell,  Arch.  Int.  Med.,  February,   1912,  ix,  No.  2,  p.  148. 

2  G.  Oliver,  Quart.  Jour,  of  Med.  Oxford,  October,  1907. 

^  L.  Bninton,  "Therapeutics  of  the  Circulation,"  P.  Blakiston's  Sons, 
1908,  p.  84. 


148  BLOOD-PRESSURE 

subject  being  utilized  as  an  indicator  or  manometer.  If 
the  veins  on  the  dorsum  of  the  hand  are  sufficiently  visible, 
we  find  that  when  the  hand  is  held  in  a  vertical  position 
with  the  fingers  extended,  and  is  slowly  raised,  the  veins 
at  a  certain  height  above  the  level  of  the  apex  of  the  heart 
can  be  seen  to  collapse  rather  suddenly. 

Oliver  states  that  at  the  moment  of  collapse  of  the  veins 
the  blood-pressure  within  them  is  practically  nil,  being 
balanced,  as  it  were,  by  the  force  of  gravity.  We  may, 
therefore,  express  this  force,  annulling  the  hydrostatic 
rise  of  the  blood,  in  millimeters  of  mercury.  This  may 
be  done  by  making  a  very  simple  calculation.  If  we  take 
the  average  specific  gravity  of  the  blood  as  1.060  and 
that  of  mercury  as  13,570,  the  25.5  mm.  of  blood  contained 
in  1  in.,  will  represent  1.985  mm.  Hg.  (or  approximately 
2  mm.  Hg.) ;  therefore,  if  we  multiply  by  2  the  number 
of  inches  above  the  level  of  the  apex  of  the  heart  when 
the  veins  collapse,  we  ascertain  in  millimeters  of  mercury 
the  venous  pressure.  According  to  Oliver,  this  simple 
method  of  measuring  the  venous  pressure  affords  uniform 
results  and  is  definite  and  delicate  as  it  enables  one  to 
discriminate  between  differences  of  1  mm.  It  is  im- 
portant to  see  that  the  pressure  is  not  artificially  raised. 
This  may  occur  through  nervous  perturbation  or  by 
obstruction  of  the  venous  flow  by  tight  clothing. 

In  making  any  observations  upon  the  veins,  the  arm 
should  be  maintained  in  a  position  such  that  the  point  of 
pressure  is  about  at  the  level  of  the  heart,  irrespective  of 
the  position  of  the  patient.  If  this  detail  is  not  regarded, 
the  force  of  gravity  will  enter  in  and  invalidate  the  findings. 

Venous   pressure  readings  are  also   influenced   by   the 


VENOUS    AND    CAPILLARY   BLOOD-PRESSURE  149 

surrounding  temperature  and  by  the  thickness  of  the 
skin  over  the  vein  which  is  being  tested,  and  also  by  the 
prominence  of  the  superficial  veins  and  the  presence  or 
absence  of  phlebosclerosis  (said  to  be  of  frequent  occurrence 
by  Hoobler  and  Eyster)  and  edema. 

OUR  PRESENT  KNOWLEDGE  OF  THE  PHYSICS  AND  PHYSIOLOGY 
OF   VENOUS   BLOOD-PRESSURES 

Regarding  the  variations  of  pressure  in  different  parts  of 
the  venous  system  very  little  is  definitely  known,  some 
authorities  believing  that  there  exists  a  negative  pressure 
in  the  great  veins  near  the  heart  while  others  contend  that 
a  positive  pressure  within  the  vense  cavse  is  essential  to 
normal  auricular  function. 

Until  quite  recently  we  have  assumed  that  venous 
pressure  passively  responds  to  changes  in  the  peripheral 
resistance  and  that  it  rises  and  falls  inversely  with  the 
pressure  within  the  arterial  tree.  There  is  now  a  growing 
belief  supported  in  part  by  experimental  work  (some 
performed  as  early  as  1890)  on  both  men  and  animals, 
that  the  pressure  in  the  venous  side,  may  be  and  probably 
is,  dominated  by  a  special  nervous  mechanism.  For  we 
now  know  that  the  veins  are  supplied  with  motor  nerves 
and  it  has  been  shown  that  the  veins  respond  to  epinephrin 
by  constricting^  while  Crawford  and  Twombly^  have 
shown,  in  addition  to  this  action,  that  marked  constriction 
of  the  vein  occurs  when  subjected  to  a  solution  of  epi- 
nephrin of  the  strength  of  1  to  60,000,  even  when  entirely 
freed  from  vasomotor  control. 

^  Dunn  and  Chavasse,  Proc.  Royal  Society,  London,  Ixxxvi,  1912. 

2  A.  C.  Crawford  and  M.  M.  Twombly,  N.  Y.  Med.  Jour.,  Aug.  16,  1913. 


150  BLOOD-PRESSURE 

Capps  and  Mathews^  have  made  a  careful  study  of 
the  subject  of  venous  pressure  and  have  correlated  the 
available  experimental  and  clinical  data  in  substantiation 
of  the  value  of  further  studies  in  venous  pressure. 

MalP  in  1892  demonstrated  that  the  portal  vein  is 
controlled  by  constrictor  fibers  from  the  splanchnic  nerves, 
and  considerable  proof  has  been  offered  by  Roy  and 
Sherrington^  to  show  that  the  systemic  veins  also  are  sup- 
pHed  by  vasomotor  nerves.  Other  valuable  contributions 
to  our  knowledge  of  venous  pressure  have  been  made  by 
Frey/  von  Basch/  Bayliss  and  Starling,®  and  Sewall.^ 

On  the  clinical  side,  investigations  are  meager  as  yet. 
Calvert^  called  attention  to  the  value  of  a  rising  venous 
pressure  as  a  danger  signal  in  pleural  effusions.  Hooker 
and  Eyster^  carried  out  a  series  of  observations  on  venous 
pressure  changes  in  various  diseases  of  the  heart  without 
conclusive  results. 

That  the  veins,  like  the  arteries,  have  the  power  to 
maintain  their  blood-pressure  within  wide  limits  was 
emphasized  by  Moritz  and  Tabora^"  who  found  that  it 
was  necessary  to  withdraw  over  500  c.c.  of  blood  by 
venesection  in  a  human  being,  before  any  appreciable  fall 
in  the  venous  pressure  occurred. 

1  J.  A.  Capps  and  S.  A.  Mathews,  Jour.  A.  M.  A.,  Aug.  9,  1913,  vol.  Ixi. 
No.  6,  p.  388. 
«  Arch.  f.  Physiol,  1892,  p.  409. 
»  Jour.  Physiol,  1890,  xi,  85. 

*  Deutsch.  Arch.  f.  klin.  Med.,  1902,  Ix-xiii,  511. 
'  Wien.  med.  Prcsse,  1904,  xx,  962. 

•  Jour.  Physiol,  1894,  xvi,  159. 

'Henry  Sevvall,  Jour.  A.  M.  A.,  Oct.  20,   1906,  p.   1279. 

^  Bull   Johns   Hopkins   Hos.,   February,    1908. 

»  Bull  Johns  Hopkins  Hos.,  1908,  p.  274. 

"  Verhandl  d.  Ver.  d.  inn.  Med.  Berlin,  1909,  p.  379. 


VENOUS    AND    CAPILLARY   BLOOD-PRESSURE  151 

Yandell  Henderson^  has  advanced  the  plausible  hy- 
pothesis that  the  function  of  the  venopressor  (constricting) 
mechanism  is  essential  to  maintain  an  optimum  feeding 
pressure  to  the  heart.  This  theory  is  further  substantiated 
by  the  newer  researches  of  Hooker^  on  venous  blood- 
pressure  in  man.  He  finds  that  normal  venous  pressure  is 
independent  of  the  ordinary  changes  in  peripheral  arterial 
resistance  and  that  the  capacity  of  the  veins  may  vary 
without  affecting  the  internal  pressure. 

Factors  Influencing  Venous  Pressure. — Effect  of  Posture 
on  Venous  Pressure. — Change  of  posture  from  the  erect  to 
the  horizontal  causes  a  fall  in  venous  pressure,  while 
change  of  posture  from  the  horizontal  to  the  erect  causes  a 
rise  in  venous  pressure.  In  the  extensive  researches 
of  Barach  and  Marks^  these  changes  uniformly  occurred. 

The  position  of  the  part  in  relation  to  the  heart  is  an 
important,  if  not  the  most  important  factor  determining 
venous  pressure  in  the  normal  person.  Although  we  find 
that  the  veins  of  the  feet  do  not  exhibit  the  degree  of 
pressure  as  compared  with  the  arm,  that  would  be  expected 
if  calculated  on  the  basis  of  position  (von  Recklinghausen). 

Exercise  either  local  or  general  causes  a  slight  rise  (to 
about  twice  the  normal  pressure);  the  same  may  result 
from  sudden  change  in  external  temperature.  Actual 
arterial  pressure  does  not  affect  the  venous  pressure 
nearly  as  much  as  does  general  cardiac  decompensation 
and  failure  of  the  right  heart.  The  smaller  capillaries  are 
probably  more  dependent  for  their  changes,  upon  venous 
pressure  than  upon  arterial  pressure. 

^  Henderson  and  Barringer,  Am.  Jour.  Physiol.,  1913,  xxxi,  352. 
'  Amer.  Jour.  Physiol.,  1914,  xxxii. 
«  Arch.  Int.  Med.,  May  15,  1913,  No.  5. 


152  BLOOD-PRESSURE 

Respiratory  Variation. — There  is  a  respiratory  variation 
occurring  in  the  external  jugular  amounting  to  from 
3  to  4  cm.  of  water. 

Defective  cardiac  action,  particularly  that  of  the  right 
heart  results  in  venous  stasis  which  is  accompanied  by  a 
rise  in  venous  pressure. 

Myocardial  degeneration  is  accompanied  by  a  marked  rise 
in  venous  pressure  which  may  exceed  25  cm.  of  water  at 
the  cardiac  level. 

Intravenous  Injection. — This  procedure  causes  a  tem- 
porary increase  in  venous  pressure  which,  in  proportion, 
affects  venous  more  than  it  does  arterial  pressure. 

External  Compression. — Anything  which  generally  com- 
presses the  veins  in  any  unit  of  the  body,  as  an  ex- 
tremity or  the  abdomen,  will  increase  venous  pressure. 
This  fact  is  important  in  connection  with  the  care  of  chronic 
cardiac  decompensation  and  this  knowledge  may  be  em- 
ployed to  prevent  syncope  after  tapping. 

Diurnal  Rhythm. — According  to  Hooker^  the  venous 
pressure  in  man  exhibits  a  diurnal  rhythm,  rising  through- 
out the  day  from  10  to  20  cm.  of  water  and  falling  again 
during  the  night.  Thus  his  average  figures  are  by  day  15 
cm.  of  water,  at  night  during  sleep  7  to  8. 

Relation  of  Pulse  Pressure  to  Venous  Pressure. — The 
tendency  for  both  pulse  pressure  and  venous  pressure  is 
to  increase  simultaneously  in  cardiac  cases,  irrespective  of 
the  lesion. 

The  Normal  Venous  Pressure. — As  may  be  expected  from 
the  preceding  and  from  the  marked  influences  of  gravity, 
posture  and  other  ever-present  factors,  there  are  as  yet  no 

1  Am.  Jour.  Physiol.,  1913,  xxxii,  356. 


VENOUS    AND    CAPILLARY   BLOOD-PRESSURE  153 

very  narrow  limits  which  may  be  considered  as  determining 
normal  venous  pressures.  That  the  figures  given  below 
are  clinically  satisfactory  is  shown  by  the  work  of  Hooker 
and  Eyster^  who  studed  venous  pressure  in  the  facial  vein 
and  the  external  jugular  in  dogs  taking  simultaneous  ob- 
servations by  the  direct  method  of  placing  a  canula  in  the 
facial  vein  and  studying  the  external  jugular  by  the  indirect 
method  and  by  comparison,  obtained  variations  rarely 
exceeding  one  (1)  cm.  of  water. 

Average  Venous  Pressxire 
Normal  Cardiovascular 


Av.  Variations  Av.  Variations 

Howell 7.6  cm.  4  to  13  cm.        13.9  cm.        7  to  25  cm. 

Hooker   \ 

Eyster     ( ^"^  ^°^- 


Moritz  and  v.  Tabora.  4  to    8  cm. 

Standing 


Highest 
32  cm. 


Barach  and  Marks.. .  .    11.2  cm. 


8  to  18  cm. 
Horizontal 
3.5  to  11  cm. 

Clinical  Importance  of  Venous  Pressure. — From  our 
present  knowledge  of  the  physiology  of  the  circulation  and 
of  its  pathologic  change  in  cardiac  decompensation,  there  is 
little  doubt  that  the  venous  pressure  plays  an  important 
part  in  the  proper  filling  of  the  heart  chambers  and  that  a 
normal  venous  pressure  at  the  level  of  the  heart  is  essential 
to  a  normal  cardiac  output.  This  is  shown  to  be  true  at  least 
in  part  by  the  fact  that  pulse  pressure  and  venous  pressure 
vary  simultaneously  in  health  (see  above),  also  by  the  evident 
over-distention  of  the  veins  in  cardiac  decompensation 
from  whatever  cause,  and  the  marked,  and  sometimes 
spectacular,    relief   afforded   by   appropriate   and   timely 

^  hoc.  cit. 


154  BLOOD-PRESSURE 

venesection.  These  facts  all  indicate  that  venous  pres- 
sure, when  high,  is  at  least  one  factor  which  interferes  with 
the  normal  action  of  the  auricle,  rendering  it,  for  the  time, 
powerless  to  functionate  properly  until  relieved  by  a  vigorous 
reduction  in  venous  pressure.  In  this  connection,  Bishop 
has  pointed  out  that  in  determining  the  seriousness  of 
arterial  hypotension,  the  chief  factor  is  the  approximation 
of  venous  and  arterial  pressure,  and  that  a  low  pressure 
need  not  necessarily  be  serious,  per  se,  unless  the  venous 
pressure  is  abnormally  high,  and  further  that  it  is  this 
altered  relation  between  the  normal  venous  and  arterial 
pressures  that  determines  the  seriousness  of  general  venous 
congestion. 

Concerning  pulmonary  venous  pressure,  we  have  no 
method  of  clinical  value  by  which  the  degree  and  changes 
in  pulmonary  venous  pressure  may  be  determined.  Clinical 
phenomena,  particularly  the  wetness  or  dryness  of  the  lungs 
in  cardiac  cases  will  determine  this. 

Effects  of  Drugs  on  Venous  Tension. — A  carefully 
planned  and  rigidly  checked  series  of  experiments  by  Capps 
and  Mathews^  are  worthy  of  consideration  as  they  com- 
prise almost  our  sole  accurate  data.  They  employed  the 
method  of  Moritz  and  Tabora  (see  page  146).  The  sum- 
mary of  their  results  is  as  follows: 

Digitalis  Group. — Digitalis  Hso  to  H20  gr.,  digipuratum 
1  c.c,  strophanthin  H20  to  }4o  gr.,  all  used  intravenously. 
No  effect  on  venous  pressure. 

Epinephrin. — 1.2  to  10  min.  1-1000  sol.  diluted  in  20  c.c. 
salt  solution.  Small  doses  no  effect,  large  doses  rise  in 
venous  pressure  from  10  to  80  mm.  H2O. 

*  Loc.  cit. 


VENOUS    AND    CAPILLARY   BLOOD-PRESSURE  155 

Pituitrin. — 1  c.c.  10  per  cent.  sol.  Same  as  epinephrin 
but  less  marked  effect. 

Caffein. — Caffein  sodium  benzoate  3^  to  2  gr.,  no  efifect. 

Strychnin  Sulphate. — No  effect  except  in  toxic  quanti- 
ties, then  a  rapid  rise  in  venous  pressure. 

The  Nitrites. — Amyl  nitrate  and  nitro-glycerin  ^^50  to  J^o 
gr.  caused  a  decided  fall  in  venous  pressure. 

Morphine. — %  to  %  gr.  No  effect  on  venous  pressure. 
3^  to  3^  gr.     Slight  fall  in  venous  pressure. 

Alcohol. — 25  to  30  per  cent,  strength  10  to  50  c.c.  in 
amount.  Small  doses  no  effect,  large  doses  rise  in  venous 
pressure.  This  rise  was  in  proportion  to  the  degree  of 
disturbance  of  heart  action. 


CHAPTER  IX 
CLIMATOLOGIC  AND  RACIAL  INFLUENCES 

Absolute  and  Relative  Blood-pressure. — Throughout 
the  discussion  of  this  subject,  the  relative  blood-pressure 
only  has  been  considered,  that  is,  the  degree  of  arterial 
pressure  over  and  above  barometric  pressure  at  the  time 
of  the  observation.  This  has,  from  a  clinical  standpoint, 
been  clearly  demonstrated  to  be  the  important  factor,  as 
ordinary  studies  do  not  involve  a  determination  of  the 
absolute  blood-pressure,  i.e.,  the  systolic  pressure  plus  the 
actually  determined  barometric  pressure  at  the  time  of  the 
observation.  It  may  be  stated  in  passing  that  changes  in 
atmospheric  pressure  are  accompanied  by  approximately 
equal  changes  in  the  absolute  blood-pressure,  usually  in 
the  same  direction. 

Altitude. — In  approaching  the  subject  of  the  effect  of 
altitude  on  blood-pressure  and  pulse  rate,  a  sharp  line 
must  be  drawn  between  the  influence  of  changes  in  altitude 
(atmospheric  pressure)  upon  normals  and  other  individ- 
uals, particularly  the  tuberculous;  otherwise  confusion  will 
surely  follow,  because  the  great  bulk  of  clinical  data  dem- 
onstrates that  altitude  affects  normal  and  pathologic  in- 
dividuals differently. 

Effect  of  High  Altitude  on  Healthy  Individuals. — 
Gardner  and  Hoagland,^  at  an  altitude  of  6000  ft.,  meas- 

*  Gardner  and  Hoagland,  Trans.  Amer.  Climat.  Assn.,  1905. 

156 


CLIMATOLOGIC    AND    RACIAL   INFLUENCES  157 

ured  large  numbers  of  normals  who  had  lived  in  Colorado 
for  more  than  a  year,  and  concluded  that  the  average  blood- 
pressure  was  sHghtly  lower  than  at  the  sea  level,  although 
prolonged  residence  at  that  altitude  does  not  materially 
affect  blood-pressure. 

Experiments  showed  that  an  ascent  from  6000  to  14,000 
lowered  pressure  and  increased  pulse  rate.  The  fall  was 
apparently  a  permanent  one,  although  the  fall  which  im- 
mediately follows  the  change  in  altitude  is  temporarily 
greater  than  is  the  case  after  the  individual  becomes  accus- 
tomed to  the  alteration  in  altitude. 

Smith  at  Ft.  Stanton^  (6200  ft.)  states  that,  ''It  has 
been  scientifically  established  that  blood-pressure  is  low- 
ered with  increased  altitude." 

Pomeroy^  in  order  to  determine  the  degree  of  variation 
in  the  systolic  and  diastolic  blood-pressure,  caused  by 
changes  of  altitude,  averaged  the  observations  of  eighteen 
investigators,  dating  from  1878  up  to  the  date  of  this  writ- 
ing and  including  himself.  He  found  that  the  fall  in  sys- 
tolic blood-pressure  ranged  between  1  and  22  mm.  Hg., 
and  the  diastolic  fall  was  between  1  and  11  mm.  Hg. 

The  effect  of  sudden  changes  in  altitude  in  the  upward 
direction  results  usually  in  an  increase  in  systolic  pressure, 
an  increase  in  diastolic  pressure,  with  very  little  if  any 
significant  change  in  pulse  pressure.  These  changes  were 
accompanied  by  nose-bleed  and  headache.^  In  another 
group  which  were  largely  pathologic,  no  such  changes  were 
noted. 

In  order  to  determine  the  effect  of  increased  atmospheric 

»  Reprint  No.  51,  Public  Health  Rep.,  P.  H.  and  M.  H.  Service. 

2  Int.  Med.  Jour.,  Vol.  xviii,  p.  731. 

'Personal  communication  from  Dr.  Harley  Stamp. 


158  BLOOD-PRESSURE 

pressure  upon  the  blood-pressure  and  pulse  rate,  Brooks* 
studied  seventy-five  compressed-air  workers,  when  contrary 
to  the  findings  of  earlier  investigators,  he  found  that  only 
rarely  did  there  occur  a  marked  rise  in  arterial  pressure, 
even  in  workers  subjected  to  a  pressure  of  plus  31  lb., 
as  in  no  cases  examined  by  him  was  blood-pressure  or  pulse 
rate  materially  altered.  Further  observations,  if  in  accord 
with  these,  would  be  of  value  in  demonstrating  the  degree 
of  danger  involving  cassion  workers  who  are  subjects  of 
cardiovascular  and  renal  impairments. 

Blood -pressure  in  Deep  Mines. — Investigations  after 
descent  into  the  Butte  mines,  to  a  depth  of  2600  ft.  below 
the  surface,  was  made  in  an  effort  to  determine  the  effect 
of  this  change  upon  blood-pressure.  The  usual  effect  was 
found  to  be  a  fall  in  both  systolic  and  diastolic  pressure 
with  a  primary  increase  in  pulse  pressure,  which  tended 
in  a  short  time  to  return  toward  normal  values.  ^ 

Schneider  and  Hedblom^  present  a  very  concise  and 
accurate  summary  of  present  knowledge  bearing  on  this 
point. 

1.  A  considerable  elevation  in  altitude  tends  to  lower 
systoUc  and  diastolic  blood-pressure  and  to  increase  the 
heart  rate. 

2.  The  fall  of  systolic  pressure  is  slightly  greater  and 
more  certain  to  occur  than  the  fall  of  diastolic  pressure. 

3.  A  rise  in  diastolic  pressure  occurs  in  some  individuals. 

4.  The  influence  of  such  factors  as  psychic  states,  eating 
and  exercise  may  obscure  the  findings. 

^  H.  Brooks,  Med.  Rec,  May  25,  1907. 

'  Personal  communication  from  Dr.  Harley  Stamp. 

'  Am.  Jour.  Physiol.,  Vol.  xxiii,  No.  2. 


CLIMATOLOGIC    AND   RACIAL   INFLUENCES  159 

5.  The  fall  in  blood-pressure  and  increase  in  heart  rate 
are  more  marked  in  the  early  part  of  stay  in  high  altitudes. 

6.  With  prolonged  stay  in  high  altitudes  the  heart  rate 
probably  returns  more  nearly  to  normal  than  the  blood- 
pressure  of  all  individuals. 

7.  High  altitudes  do  not  affect  in  the  same  degree  all 
individuals. 

8.  Small  elevations  in  altitude  do  not  materially  influence 
blood-pressure. 

9.  Those  individuals  most  affected  by  high  altitudes 
seem  to  sustain  the  greater  fall  in  systolic  blood-pressure 
and  the  greater  acceleration  in  heart  rate. 

10.  The  heat  of  the  summer  season  probably  accelerates 
the  pulse  rate. 

11.  Moderate  variations  in  altitude  are  not  of  themselves 
inimical  to  residence  or  physical  activity  in  persons  having 
definite  cardiovascular  or  nephritic  lesions. 

Tuberculosis. — ^LeRoy  S.  Peters,  pointed  out  in  1908^ 
that  altitude  usually  caused  a  rise  in  blood-pressure  in  the 
tuberculous.  He  made  his  observations  at  an  altitude  of 
6000  ft.  (For  effect  of  tuberculosis  on  blood-pressure  see 
Chapter  XIV.) 

Bullock^  confirms  the  observations  of  Peters.  The 
blood-pressure  raising  effect  of  altitude  on  persons  suffering 
from  pulmonary  tuberculosis  appears  to  be  of  distinct 
advantage  to  the  patient,  as  it  directly  combats  the  blood- 
pressure  reducing  acting  of  tuberculotoxins  by  altering 
metabolism,  modifying  and  stimulating  tissue  change,  and 
aiding  elimination. 

^Arch.  Int.  Med.,  August,  1908. 
2  Jour.  A.  M.  A.,  June  19,  1909. 


160 


BLOOD-PRESSURE 


B.  R.  Hooker^  shows,  in  his  reports  of  respiratory  cases, 
that  placing  patients  in  the  open  air  increased  the  blood- 
pressure  from  5  to  10  mm. 

Influence  of  Climate. — Weston  P.  Chamberlain  has 
recently  reported  in  the  Philippine  Journal  of  Science^ 
an  exhaustive  study  of  the  effect  of  climate  and  race  upon 
the  normal  average  blood-pressure  readings.  The  study 
is  based  upon  6128  blood-pressure  observations  on  1042 
white  men  and  552  Filipinos  all  in  good  health  and  ranging 
in  age  from  twenty  to  forty  years.  The  average  systohc 
pressure  of  5368  readings  on  992  persons,  was  115.6  mm. 
and  the  pulse  rate  taken  simultaneously  averaged  81 
beats  per  minute.  The  average  age  was  26.6  years. 
Comparing  this  average  with  that  of  Woley  (see  page  42) 

Chamberlain's  Table. — Average  systolic  blood-pressures  and  pulse 
rates,  based  on  5368  observations  of  each  which  were  made  on  992  Ameri- 
can soldiers  serving  in  the  Philippines;  arranged  according  to  age.  (12.5- 
cm.  armlet.) 


Aver- 
age 
age, 
years 

Number  of  men  showing  pressures  from — 

Total 
num- 
ber of 
men 

Aver- 
age 
pres- 
sure 

Aver- 
age 

pulse 
rate 

Age 
period, 
years 

91 

to 

100 

mm. 

101 

to 

110 

mm. 

111 

to 
120 
mm. 

121 

to 

130 

mm. 

131 

to 

140 

mm. 

141 

to 

150 

mm. 

151 

to 

160 

mm. 

18  to  20 
20  to  25 
25  to  30 
30  to  35 
35  to  40 
Over  40 

19.4 

22.8 
27.2 
32.6 
37.5 
43.1 

1 
32 
16 

2 

2 

12 

156 

73 

34 

9 

3 

13 
165 
108 
42 
24 
17 

8 
87 
70 
23 
14 

7 

1 

22 

13 

7 

8 

2 

1 

5 
3 
1 
3 
2 

2 
3 

1 

36 

469 

286 

109 

58 

34 

Mm. 
115.0 
114.3 
115.9 
116.7 
120.5 
119.6 

78 
82 
81 
80 
81 
79 

Totals  or 
averages 

26.6 

53 

287 

369 

209 

53 

15 

6 

992 

115.6 

81 

1  Med.  Rec,  Jan.  28,  1911. 

2  December,  1911,  Vol.  vi,  No.  6,  Sec.  B. 


CLIMATOLOGIC    AND    RACIAL   INFLUENCES  161 

it  is  found  to  be  7  mm.  lower  and  compared  to  Bachman^ 
3  mm.  lower.  While  the  pulse  rate  in  Chamberlain's  series 
was  9  beats  per  minute  above  the  average  accepted  as 
normal  in  temperate  climates  for  all  ages.  He  also  found 
that  the  blood-pressure  has  a  tendency  to  be  lower  than 
the  averages  given  above,  during  the  first  three  months 
stay  in  tropical  climates. 

Racial  Influence  on  Blood-pressure. — Chamberlain  also 
reported^  a  series  of  observations  conducted  to  determine 
the  effect  of  race  upon  average  systolic  blood-pressure  and 
obtained  the  following  result : 

Average  blood-pressure  of  100  Filipino  scouts,  115.0 
Average  blood-pressure  of  100  Philippine  soldiers,  115.9 

and  states  that  "we  may,  therefore,  conclude  that  the  mean 
blood-pressure  for  Filipinos  of  from  fifteen  to  forty  years  of 
age  (average  age  twenty-five  years)  is  115  to  116  mm.  and 
that  it  does  not  differ  from  the  pressure  at  the  same  age 
for  Americans  residing  in  the  Philippines." 

Normal  Blood-pressure  Studies  in  the  American  Indian. 
— The  investigations  of  Dr.  Harley  Stamp  who  was  at- 
tached to  an  archaeological  exposition  sent  out  by  the 
University  of  Pennsylvania  headed  by  Dr.  Frank  G.  Speck, 
have  brought  out  some  very  interesting  points  in  connection 
with  the  comparative  study  of  blood-pressure.  These 
observations  for  the  most  part  were  carried  on  in  the 
winter  of  1913-14  to  the  number  of  many  thousand  upon 
fifty-seven  tribes  of  American  Indians,  and  often  at  from  20° 
to   30°  below  zero.     Another  group  of  the  observations 

1  N.  Y.  Med.  Jour.,  1911. 

2  Loc.  cit. 
11 


162  BLOOD-PRESSURE 

was  made  at  the  Carlisle  Indian  School,  thereby  giving 
some  comparative  data  as  to  the  effect  of  civilization 
upon  blood-pressure  in  the  American  aborigine.  In 
summarizing  these  observations  it  may  be  said  that  the 
effects  of  exercise  probably  subside  more  quickly  in  the 
Caucasian  than  in  the  American  Indian.  ''The  effects  of 
low  temperatures  were  undoubtedly  very  noticeable;  the 
effects  also  of  the  habits,  not  only  in  reference  to  their  food 
but  also  to  the  lack  of  sanitary  requirements,  even  of  the 
most  primitive  kind." 

These  observations  were  all  made  by  accepting  the  first 
point  as  the  systolic  and  the  fifth  point  as  the  diastolic 
pressure  criterion.  The  individual  ages  ran  from  two 
months  to  103  years,  and  the  Indians  were  of  all  sizes,  the 
same  as  found  in  any  Caucasian  community.  There  were 
among  them  approximately  the  same  proportion  of  good 
muscular  development. 

The  diurnal  and  periodic  changes  showed  no  differences 
from  similar  observations  upon  Caucasians,  while  emotion 
causes  a  far  greater  variation  in  the  Indian  than  in  his 
white  brother. 

This  investigator  is  inclined  to  believe  that  the  in- 
dividual inclines  to  become  acclimated  to  low  tempera- 
tures, which  causes  the  variation  to  become .  less  as  the 
low  temperatures  are  endured.  There  was  no  difference 
noted  in  the  effect  of  postural  changes,  or  of  alcoholic  in- 
dulgence. In  the  use  of  tobacco  there  is  a  marked  differ- 
ence in  the  effect  on  the  two  peoples.  This  seems  to  be 
due  to  excessive  smoking  and  to  the  use  of  "doped"  to- 
bacco by  the  Indian.  Much  of  this  is  taken  in  the  form 
of  snuff.     The  tea  habit  seems  well  formed  and  the  record 


CLIMATOLOGIC    AND    RACIAL    INFLUENCES  163 

is  made  of  a  guide  who  drank  forty-two  cups  of  strong  tea 
a  day. 

The  normal  age  charts  of  blood-pressure  records  upon 
the  American  Indian  differ  but  slightly  from  those  of  the 
white  except  that  there  seems  to  be  a  uniform  tendency  to 
reduced  blood-pressure  at  or  about  the  forty-fifth  year. 


CHAPTER  X 

PHYSICAL  FITNESS,  EXERCISE  AND  ATHLETICS 

THEIR  EFFECT  UPON  AND  RELATION  TO 

BLOOD-PRESSURE 

General  Considerations. — The  physiology  and  pathology 
of  exercise  are  chapters  in  medicine  which  have  just  begun 
and  in  which  there  is  much  to  be  written.  A  number  of 
facts,  however,  have  been  established  which  permit  of 
certain  generalizations,  this  being  particularly  true  of  our 
knowledge  of  the  response  of  the  heart  to  changes  in  the 
circulation  induced  by  muscular  activity,  and  it  is  generally 
recognized  that  no  one  should  be  permitted  to  engage 
in  exhausting  sports  or  unusual  physical  exertion,  who 
does  not  possess  an  effective  cardiovascular  system,  which 
will  insure  him  against  possible  untoward  results  from  the 
ex;traordinary  effort. 

Thus  we  find  that  a  careful  and  thorough  physical  ex- 
amination, with  special  reference  to  the  condition  of  the 
heart,  circulation  and  kidneys  made  by  a  competent 
medical  examiner,  has  become  a  recognized  practice 
in  most  gymnasia  and  athletic  institutions,  where  youths 
train  and  engage  in  competitive  athletics. 

The  indulgence  in  athletics  as  a  means  of  preserving 
health  and  physical  well-being,  and  the  rational  employment 
of  special  exercises  as  one  of  the  devices  of  physical  therapy 
now  demand  of  the  active  physician  a  comprehensive  under- 

164 


PHYSICAL   FITNESS,    EXERCISE    AND    ATHLETICS  165 

standing  of  certain  physiologic  phenomena  and  the  con- 
sequences following  various  forms  of  muscular  activity. 

CARDIAC   EFFICIENCY   IN   RELATION   TO   EXERCISE 

As  it  is  clearly  evident  that  the  response  of  the  cardio- 
vascular system  to  muscular  effort  depends  largely  upon 
the  integrity  of  the  musculature  of  the  heart,  it  follows 
that  in  approaching  this  subject  the  dividing  line  must 
be  sharply  drawn  between  individuals  having  abnormalities 
of  the  heart  and  arterial  systems  and  those  whose  cir- 
culatory apparatus  is  intact. 

Extreme  caution  should  be  exercised  before  permitting 
active  muscular  exertion  and  competitive  exercise  to 
individuals  who  are  known  to  have  cardiovascular  and 
renal  defects,  and  when  permitted  always  should  be 
under  constant  competent  supervision.  This  does  not 
mean  that  the  presence  of  cardiac,  renal  and  vascular 
defects,  per  se,  preclude  indulgence  in  all  forms  of  sports 
and  exercises;  indeed  the  judicious  employment  of  prop- 
erly supervised  and  carefully  adjusted  muscular  effort, 
including  certain  mild  sports,  should  form  a  large  part  of 
the  medical  care  of  persons  coming  under  this  group. 

Cardiac  efficiency  or  cardiac  effectiveness  means  cardiac 
muscle  integrity,  and  this  in  turn  implies  not  only  an 
ability  of  the  heart  to  supply  the  normal  demands  of 
everyday  life,  but  also  an  ability  to  respond  to  extraor- 
dinary demands  in  such  a  manner  that  an  adequate  circula- 
tion will  be  maintained. 

It  is  believed  that  the  normal  heart  in  youth  with  the 
body  at  rest,  does  not  expend  more  than  one-twelfth  of  its 
potential  or  reserve  energy.     Under  ordinary  conditions 


166  BLOOD-PRESSURE 

of  active  life,  involving  moderate  work,  from  one-fourth 
to  one-third  of  reserve  power  is  called  out,  while  the 
full  capacity  is  only  demanded  by  the  most  severe  forms  of 
exercise  demanding  great  endurance.  This  reserve  or 
potential  energy  is  closely  related  to  the  demands  of  the 
tissues  and  organs  for  additional  blood.  With  the  body  at 
rest  it  is  estimated  that  60  c.c.  of  blood  is  expelled  from  the 
heart  at  each  systole,  at  the  rate  of  seventy-two  times 
per  minute.  Upon  demand  this  volume  output  may  be 
increased  sixfold,  the  increase  in  output  being  partly  the 
result  of  an  increased  cardiac  rate  and  partly  an  increased 
systolic  capacity. 

The  whole  question  of  cardiac  efficiency  hinges  upon  the 
presence  of  an  adequate  potential  reserve  or  factor  of  safety, 
and  the  development  of  cardiac  insufficiency  is  almost 
wholly  dependent  upon  the  degree  of  reduction  in  cardiac 
reserve  as  compared  with  the  demands  for  the  expenditure 
of  excess  energy.  It  is  upon  these  two  factors,  cardiac 
reserve,  and  the  demand  for  expenditure  of  energy  that  the 
degree  of  physical  fitness  depends. 

Concerning  the  formulation  of  hard  and  fast  rules,  regula- 
tions and  restrictions,  for  the  guidance  and  control  of  in- 
dividuals with  such  defects,  very  little  can  be  said,  as  every 
case  differs  from  every  other  and  should  be  governed  by 
mature  judgment,  based  upon  the  results  of  careful  physical 
examination,  functional  tests  and  experimental  exercises. 

Given  an  evident  "pathologic  fault,"  the  most  practical 
means  at  our  disposal  with  which  to  corroborate  and 
qualify  the  results  of  the  physical  examination  are,  an 
analysis  of  the  urine  and  a  study  of  blood-pressure,  es- 
pecially noting  in  the  latter,  variations  in  systolic,  diastolic 


PHYSICAL    FITNESS,    EXERCISE    AND    ATHLETICS  167 

and  pulse  pressures,  and  also  pulse  rate  under  changing 
conditions  of  rest  and  exercise.  The  so-called  functional 
tests  (see  Chapter  XIX,  page  331)  should  be  appUed  to  all 
except  adolescents  and  youths.  A  pathologic  lu-inary 
finding  will,  of  course,  be  given  its  proper  value,  and  be 
collated  with  the  other  evidence  at  hand. 

Valvular  defects  alone  have  little  effect  upon  normal 
blood-pressure  values,  especially  in  the  young,  excepting 
those  with  aortic  regurgitation,  and  in  those  past  middle 
life,  whose  reserve  has  become  reduced  and  where  vascular 
and  renal  degenerative  changes  contribute  to  the  circulatory 
instability. 

Concerning  the  piu'e  forms  of  cardiac  hypertrophy, 
such  as  occur  in  the  absence  of  valvular  lesions  or  the 
history  of  previous  disease,  Barach^  is  of  the  opinion  that 
when  subjected  to  strain  they  differ  very  little  from 
normal  hearts,  as  in  a  series  of  observations  on  50  youths 
he  noted  only  the  usual  transitory  dilatation  following 
overstrain  from  long-distance  running. 

Continued  indulgence  in  athletics  is  generally  essential 
to  good  health  in  this  class,  as  exercise  tends  to  delay  the 
onset  of  degenerative  changes  which  would  follow  the 
development  of  sedentary  habits  of  life.^ 

The  discovery  of  an  abnormal  blood-pressure  value  (see 
Chapter  XVI,  page  246,  for  discussion  of  causes)  while  not  a 
cause  for  eliminating  all  exercise,  will  tend  to  move  such 
individual's  age  limit  forward  and  so  reduce  the  amount  of 
exercise  to  be  safely  indulged. 

Arteriosclerosis  even  without  hypertension  suggests  the 

1  Jour.  A.  M.  A.,  Oct.  29,  1910,  Iv,  18,  p.  1581. 

2  Robert  E.  Coughlin,  Med.  Rec,  Apr.  2,  1910. 


168  BLOOD-PRESSURE 

same  caution,  except  where  the  arterial  change  is  purely 
local  and  evidently  limited  to  the  superficial  vessels,  as  in 
those  accustomed  to  manual  labor  without  any  renal 
lesion. 

For  the  detection  of  myocardial  degeneration  and 
insufficiency  recourse  must  be  had  to  the  functional  tests, 
as  advocated  by  Graiipner,^  Boardman  Reed,^  and  others. 

Graiipner  and  others,  who  have  investigated  the  question 
of  the  rise  and  fall  of  systolic  pressure  during  and  after 
exercise,  have  found  that  normal  hearts,  those  with  well- 
compensated  valvular  lesions,  and  neurotic  hearts,  respond 
to  exercise  by  a  rise  in  pressure;  whereas  myocardial  cases 
either  fail  to  show  a  rise  or  respond  by  a  lessened  tension 
varying  from  3  to  15  mm. 

E.  Masing^  advises  a  careful  study  of  the  effect  of 
exercise  upon  the  normal  relation  between  systolic  and 
diastolic  pressure,  i.e.,  the  effect  of  exercise  upon  the  pulse 
pressure.  Thus  a  normal  circulatory  system  will  yield 
a  disproportionate  rise  in  systolic  pressure  as  compared  with 
diastolic,  thereby  producing  temporarily  an  increased  pulse 
pressure,  while  with  a  defective  circulation,  even  if  there 
occurs  a  rise  in  systolic  and  diastolic  pressures,  the  two  tend 
to  approximate  and  thus  the  pulse  pressure  becomes 
smaller. 

Age  in  Relation  to  Athletics. — In  order  to  study  the  effect 
of  exercise  upon  the  normal  individual  and  the  amount  of 
energy  expended  in  relation  to  blood-pressure  variation 
and  to  the  margin  of  cardiac  safety,  Coughlin  found  it 


1  Berl.  klin.,  1902,  xv,  174. 

2  South.  Calif.  Pract.,  August,  1910. 

»  DeuL  Arch.  f.  klin.  Med.,  1902,  Ixxiv. 


PHYSICAL    FITNESS,    EXERCISE    AND    ATHLETICS  169 

convenient  to  group  the  athletic  age  of  man  under  four 
divisions/  viz.: 

1.  Early  life,  including  infancy,  childhood  and  youth,  up 
to  twenty-one  years. 

2.  Manhood,  from  twenty  to  forty  years. 

3.  Middle  age,  from  forty  to  fifty-five  years. 

4.  Beyond  middle  life,  up  to  old  age. 

1.  Early  Life  to  Young  Manhood. — Of  first  importance  at 
the  approach  of  what  may  be  called  the  threshold  of 
athletic  life  is  the  determination  of  the  presence  or  absence 
of  cardiovascular  or  renal  abnormalities  which  might 
subject  the  individual  to  grave  danger  if  not  discovered 
before  active  athletics  are  indulged  in. 

Parents  of  growing  children  are  beginning  to  appreciate 
the  value  of  more  definite  information  concerning  their 
children's  physical  condition,  both  to  determine  the  presence 
of  possible  abnormalities,  and  also  to  avoid  the  develop- 
ment of  future  physical  defects  and  weaknesses,  through  a 
knowledge  of  the  character  and  amount  of  exertion  that 
may  be  safely  indulged  in. 

The  problem  is  frequently  brought  to  the  physician  for 
solution,  by  a  question  somewhat  like  the  following: 
''Doctor,  my  boys  are  going  to  boarding  school  this  fall 
and  I  am  anxious  to  know  whether  their  physical  condition 
is  such  that  they  may  indulge  in  track  work,  football, 
basketball,  etc." 

The  solution  of  this  problem  is  not  so  easy  as  it  ap- 
pears and  to  give  a  definite  reply  is  to  shoulder  a  great 
responsibility. 

1  R.  E.  Coughlin,  Med.  Rec,  Apr.  2,  1910. 


170  BLOOD-PRESSUBE 

Cardiac  efficiency  and  physical  fitness  are  not  necessarily 
synonymous,  for  a  poor  physique  with  a  normal  circulation 
may,  if  subjected  to  ill-advised  exertion,  rapidly  develop 
cardiovascular  deficiency,  while  under  proper  guidance  the 
same  individual  might  gradually  develop  into  a  hardy 
athlete. 

The  demonstration  of  cardiovalvular  defects,  should 
place  one  upon  their  guard,  and  the  character  and  extent 
of  exertion  permitted  will  be  determined  by  the  particular 
lesion  discovered,  the  degree  of  compensation  present  and 
the  age  of  the  individual.  Aortic  lesions  of  any  kind  and 
obstructive  lesions  of  any  valve  are  more  serious  than  a 
mitral  regurgitation  or  a  leakage  due  to  a  relative  in- 
sufficiency. All  such  cases  should  have  their  reserve  and 
muscular  efficiency  determined  by  appropriate  study  and 
tests  (see  Chapter  XIX,  page  331). 

In  giving  advice  to  the  normal  individual  in  this  class, 
the  age,  muscular  development  and  general  build,  heredity, 
past  history,  and  personal  idiosyncrasy  must  be  taken  into 
consideration. 

In  individuals  where  any  question  is  raised,  much  may 
be  done  by  a  progressively  graduated  entrance  into  ath- 
letics, in  which  the  child  or  youth  is  led  gradually  from 
mild  to  more  active  exercises,  and  so  to  the  more  exhaustive 
sports  as  his  ability  to  withstand  strain  is  demonstrated. 

In  regard  to  the  character  of  exercise  that  may  safely 
be  undertaken  in  boys'  schools,  an  editorial  in  The  Hospital 
for  April  3,  1909,  pointed  out  that  neither  age  nor  distance 
(track  athletics)  are  in  any  way  an  exact  criterion  of  the 
strain  inflicted  upon  any  given  boy  in  any  given  race,  and 
that  the  quarter-mile  is  often  far  more  exhausting,  for  most 


PHYSICAL   FITNESS,    EXERCISE    AND    ATHLETICS  171 

boys,  than  longer  distances.  This  review  also  condemns 
the  plan  of  running  boys  of  all  ages  in  the  same  heats  or 
over  the  same  distances;  because,  to  determine  the  classes 
by  age  may  mean  that  a  stocky,  well-developed  boy 
capable  of  any  exertion  may  be  sent  into  a  junior  division 
so  setting  smaller  boys  a  hot  pace  for  a  short  run,  while  an 
overgrown  but  less  precocious  boy,  perhaps  only  a  month 
older,  may  be  made  to  compete  with  the  most  athletic  of 
his  fellows  over  a  long  distance. 

An  abundant  and  somewhat  contradictory  literature  has 
grown  up  concerning  the  effect  of  exercise  on  the  heart. 
Recently  Shumacher  and  Middleton^  have  given  a  brief 
r^sum^  of  some  of  the  more  important  work.  These 
authors  incline  to  the  view  that  athletic  training  at  first 
leads  to  physiologic  hypertrophy,  but  when  prolonged  and 
markedly  severe,  it  usually  leads  to  hypertrophy  plus 
dilation  of  a  variable  degree,  frequently  marked  by  valvular 
insufficiency,  and  while  they  admit  that  such  hearts  may  be 
efficient  even  in  severe  athletic  contests,  they  nevertheless 
believe  that  the  so-called  ''athletic  heart"  is  a  distinct  dis- 
advantage to  normal  human  activities.  On  the  other 
hand,  James  Mackenzie^  seriously  doubts  the  existence  of 
any  such  pathologic  condition  and  maintains  that  "the 
evidence  on  which  such  heart  impairment  was  based, 
was  those  manifestations  of  murmurs  or  irregularities  which 
my  experience  has  shown  to  be  perfectly  consistent  with 
a  healthy  heart."  Cabot^  studied  600  consecutive  cases 
with   signs   of   cardiac   insufficiency,   for  the  purpose   of 

iL.  Shumacher  and  W.  S.  Middleton,  Jour.  A.  M.  A.,  Ixii,  p.  1136,  1914. 

^  Brit.  Med.  Jour.,   11,  p.   1697,   1912. 

3R.  C.  Cabot,  Jour.  A.  M.  A.,  Vol.  Ixiii,  p.  1461,  1914. 


172  BLOOD-PRESSURE 

determining  the  etiologic  factor  and  in  no  case  was  he 
able  to  trace  the  cardiac  impairment  to  athletics  or  to 
immoderate  exercise. 

Lee,  Dodd  and  Young^  report  a  systematic  study  of 
athletes  of  different  ages,  made  for  the  purpose  of  deter- 
mining the  etiologic  relation  of  athletics  and  strenuous 
exercise  (rowing)  to  cardiac  size  and  efficiency. 

They  divided  their  men  into  three  groups: 

1.  Freshmen. 

2.  Candidates  for  first  university  crew. 

3.  Graduates,  who  averaged  over  ten  years  of  rowing. 

Preliminary  physical  examinations  showed  all  members 
of  all  groups  to  be  free  of  cardiac  irregularity,  kidney 
involvement  or  cardiac  enlargement  as  demonstrated 
by  the  usual  methods  of  percussion  and  auscultation. 

They  found  in  group  1  an  average  heart  width  of  13  cm., 
varying  from  11.5  to  14.2  cm.  In  group  2  an  average 
cardiac  width  of  13.85  cm.,  varying  between  12.7  to  15.1 
cm.  In  group  3  an  average  cardiac  width  of  14.04  cm., 
with  variations  between  11.5  and  15.5  cm.  A  series  of 
non-athletes  showed  an  average  width  of  14  cm. 

These  studies  show  a  surprisingly  small  difference  be- 
tween any  of  the  groups,  particularly  between  those  who 
had  rowed  from  two  to  four  years  and  those  who  had 
rowed  over  ten  years,  this  difference  being  0.19  cm.  or  only 
Ka  in-  The  difference  between  groups  1  and  2  is  fully 
explained  on  the  basis  of  age  and  physical  development. 

These  authors  conclude  that  there  is  no  evidence  to  show 
that  prolonged  participation  in  rowing  under  proper  super- 

*  Rodger  I.  Lee,  Walter  J.  Dodd  and  Edward  L.  Young,  Boston  Med. 
and  Surg.  Jour.,  Sept.  30,  1915,  clxxiii,  14,  p.  499. 


PHYSICAL    FITNESS,    EXERCISE    AND    ATHLETICS  173 

vision  materially  increases  the  size  of  the  heart  which  is 
sound  at  the  beginning. 

It  may  be  concluded,  therefore,  that  in  youths  with 
normal  circulation  and  kidneys  and  average  muscular 
development,  who  have  been  physically  active  during  the 
time  of  their  early  development,  there  is  very  little  danger 
that  muscular  exercise  will  permanently  or  seriously 
damage  the  heart,  because  of  the  great  natural  reserve  and 
resilience  of  this  organ  and  of  the  arterial  coats;  but  special 
care  should  be  observed  in  permitting  active  exercise  after 
acute  illness,  particularly  the  infectious  diseases,  even 
when  mild,  because  of  the  great  tendency  of  these  diseases 
to  produce  temporary  myocardial  weakness. 

2.  Manhood  up  to  Forty  Years. — Indulgence  in  athletics 
between  the  twentieth  and  fortieth  years  in  the  absence  of 
demonstrable  cardiovascular  and  kidney  defects,  is  fraught 
with  least  danger,  as  the  majority  of  those  who  continue 
to  be  so  active,  have  grown  up  to  it,  having  followed  some 
degree  of  athletic  training  through  high  school  and  college 
and  are  therefore  well  prepared  for  such  exertion.  On 
the  other  hand,  those  not  formerly  so  inclined  are  usually 
too  busy  attending  the  urgent  demands  of  modern  life  to 
actively  indulge  in  competitive  sports;  furthermore, 
degenerative  changes  are  not  at  this  time  frequent,  so  that 
although  a  man  may  be  working  under  high  pressure,  his 
cardiac  reserve  remains  sufficient  to  cope  with  any  emer- 
gency. Regarding  the  probable  immediate  effects  of  severe 
exertion  upon  trained  athletes  prior  to  any  contest,  more 
will  be  said  in  the  section  on  functional  tests. 

3.  Middle  Age. — Regarding  the  ability  of  the  system  to 
withstand  the  strain  incident  to  strenuous  athletics  after 


174 


BLOOD-PRESSURE 


forty  years  of  age,  little  can  be  said  except  that,  given 
an  individual  accustomed  to  athletic  competition,  who 
throughout  the  greater  part  of  his  life  has  devoted  a  certain 
amount  of  time  regularly  to  such  sports,  he  may  be  per- 


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Fig.  36. — No.  26.  Male  aged  sixty-seven.  Normal.  Has  always  enjoyed 
good  health  except  for  an  occasional  attack  of  neuritis  the  result  of  exposure 
to  extremes  in  temperature.  This  patient  has  been  under  continuous  observa- 
tion for  five  years  and  the  chart  shows  a  summary  of  observations  for  each 
year.  Note  the  consistently  uniform  level  of  both  systolic  and  pulse  pres- 
sures except  for  the  first  year,  during  which  improved  hygienic  measures 
were  instituted.  The  urine  at  no  time  has  shown  any  abnormalities  and  the 
heart  has  always  been  adequate  even  after  moderate  exercise  tests  such  as 
ten  bending  movements  and  walking  up  and  down  stairs. 


mitted  to  continue,  so  long  as  physical  examination,  in- 
cluding blood-pressure  tests,  fail  to  bring  out  cardiac  over- 
strain or  cardiovascular  and  renal  degenerative  changes 
(Fig.  36).      • 


PHYSICAL    FITNESS,    EXERCISE    AND    ATHLETICS  175 

Regarding  those  who  would  take  up  active  athletics  after 
forty  years,  much  will  depend  upon  the  character  of  the 
sport  and  the  physical  fitness  of  the  individual.  Generally 
speaking  a  physically  normal  person  may  with  safety  and 
often  with  benefit  indulge  in  such  sports  as  cricket,  golf, 
rowing,  etc.,  provided  the  approach  be  gradual  and  sufficient 
time  is  consumed  in  developing  proficiency  to  allow  the 
system  to  develop  a  reserve,  i.e.,  the  performance  of  the 
greatest  amount  of  work  with  the  ^east  expenditure  of 
energy. 

Fifty-jive  Years  and  Over. — The  preceding  remarks  apply 
here  with  even  greater  rigidity,  as  there  are  few  who  can, 
with  impunity,  indulge  in  any  active  athletic  exercise  who 
have  previously  led  an  entirely  sedentary  or  passive  life. 
The  degree  of  activity  allowed  must  be  determined  in  part 
by  the  heart,  circulation,  and  kidney  condition  and  in  part 
by  the  response  by  the  individual  to  muscular  strain 
while  under  observation.  The  demonstration  of  any 
defect  should  preclude  all  violent  exertion  and  athletic 
competition. 

From  the  opposite  standpoint  a  few  important  facts  apply 
to  divisions  three  and  four.  Thus  it  is  an  accepted  fact 
that  men  over  forty  do  not  exercise  sufficiently  to  keep  up 
metabolism  and  it  is  equally  well  known  that  faulty 
metaboUsm  is  an  important,  if  not  the  most  important, 
cause  of  degenerative  changes.  So  that,  rather  than  dis- 
courage moderate  exercise  after  forty  years,  it  would  seem 
better  to  determine  carefully  the  individual's  ability  to 
withstand  exertion  and  then  judiciously  advise  systematic 
exercise,  as  there  is  no  question  that  degenerative  changes 
and  senility  may  be  greatly  delayed  by  continued  athletic 


176  BLOOD-PRESStrRE 

indulgence,  particularly  in  those  who  have  in  earlier  life 
been  athletically  inclined. 

The  Effect  of  Exercise  upon  the  Heart,  Circulation  and 
Respiration. — The  study  of  the  immediate  effects  of  pro- 
longed muscular  exertion  upon  the  normal  individual  has 
for  many  years  furnished  a  fruitful  field  for  special  in- 
vestigation. 

From  a  careful  review  of  literature  bearing  upon  this 
subject,  it  appears  that  the  earlier  conclusions  reached  by 
such  observers  as  Karrenstein^  Gartner, ^  Gordon,^  and 
Moritz^  who  believed  that  severe  exercise  resulted  in  a  fall 
in  systolic  blood-pressure,  were  not  correct,  and  that  our 
views  upon  this  subject  must  be  modified  to  conform  with 
more  recent  and  accurate  studies. 

At  present  the  consensus  of  opinion  warrants  the 
following  conclusions: 

1.  Muscular  exercise  when  sufficient  to  increase  cardiac 
activity  is  followed  by  a  rise  in  both  systolic,  diastolic, 
blood-pressure  and  pulse-rate^  and  in  venous  pressure.^ 

2.  As  a  rule,  there  is  a  greater  rise  in  systolic  pressure 
than  in  diastolic  pressure;  therefore,  exercise  normally 
increases  the  pulse  pressure,  which  may  be  interpreted  to 
indicate  an  increase  in  cardiac  output  as  well  as  an  ac- 
celeration of  its  action.''"^ 

3.  The  rise  in  systolic  pressure  continues  to  increase 

1  Amer.  Jour.   Med.  Sci.,    1912,  cxliii. 

^Zeitsch.  f.  klin.   Med.,    1903,   Vol.  1. 

'  Edinburgh  Med.  Jour.,  1907,  xxii. 

*  Deutsch.  Arch.  f.  klin.  Med.,  1903,  Ixxvii. 

'  C.  S.  Lowsley,  Med.  Jour.  Phxjsiol.,  Mar.  1,  1911. 

^  Hooker  and  Wolfsohn,  Am.  Jour.  Physiol.,  xxv,  24. 

'  Lowsley,  loc.  cit. 

8  Masing,  Deutsch.  Arch.  f.  klin.  Med.,  1902,  Vol.  Lxxiv. 


PHYSICAL    FITNESS,    EXERCISE    AND    ATHLETICS  177 

after  exercise  is  begun,  until  a  maximum  is  reached. 
A  period  of  rest  is  accompanied  by  a  decline  in  pressure, 
which  again  approaches  the  maximum  rise  as  the  exertion 
is  renewed.  The  systolic  pressure  does  not  return  to  the 
normal  level  for  some  time  after  the  muscular  effort  ceases, 
but  will  finally  fall  to  below  normal,  when  it  constitutes 
what  is  known  as  a  ''negative  phase." ^ 

4.  The  extent  of  the  rise  in  systolic  pressure  depends  on 
the  character  of  the  exercise,  upon  the  individual  and  his 
condition.  Experimenting  with  young  men  upon  a  sta- 
tionary bicycle,  Lowsley  found  that  the  time  when  the 
maximum  systolic  pressure  was  reached  varied  from  five 
to  twenty-five  minutes  and  that  the  increase  amounted  to 
from  10  to  65  mm.  with  an  average  rise  in  sixteen  minutes 
of  32.7  mm.  Apparently  the  greatest  rise  occurred  when 
the  man  was  fresh. 

5.  The  rise  in  the  diastolic  pressure  reaches  its  maximum 
either  at  the  same  time  as  the  systolic,  or  a  few  minutes 
later.  In  Lowsley's  work  cited  above,  the  rise  in  diastolic 
pressure  varied  between  zero  and  40  mm.  while  the  average 
in  seventeen  individuals  was  22.9  mm. 

The  diastolic  pressure  fluctuates  less  after  the  maximum 
has  been  reached  than  does  the  systolic.  The  return  to 
normal  after  exercise  is  slower  but  it  invariably  falls  to 
below  normal  before  the  final  balance  is  established. 

6.  The  pulse  pressure  curve  generally  follows  the  systolic, 
this  being  so  because  the  systolic  pressure  fluctuates  more 
than  the  diastolic. 

7.  The  venous  pressure  generally  rises  to  a  maximum 
rather  rapidly  and  remains  there  throughout  the  period 

1  E.  O.  Otis,  Am.  Jour.  Med.  Sci.,  Feb.  1,  1912,  cxliii.  No.  2. 

12 


178  BLOOD-PRESSURE 

of  exercise.  This  rise  rarely  amounts  to  more  than  14  cm. 
of  water.  If,  however,  the  exercise  be  not  severe  and  deep 
regular  breathing  accompanies  the  "second  wind,"  then 
the  venous  pressure  may  return  to  normal  even  during 
the  exertion.  As  a  rule  it  falls  fairly  rapidly  to  normal 
after  exercise  but  occasionally  remains  high  for  a  con- 
siderable period  (Hooker). 

8.  During  exercise  requiring  severe  strain,  with  rigid 
chest  and  closed  glottis,  the  systolic  pressure  is  increased 
more  than  the  heart  rate,  and  venous  pressure  may  be 
exceedingly  high. 

9.  The  pulse-rate  increases  rapidly  at  first  but  does  not 
usually  attain  its  maximum  as  soon  as  does  the  blood- 
pressure.  In  Lowsley's  experiments  the  average  time  for 
reaching  the  maximum  pulse  rate  was  35.4  minutes, 
and  the  average  increase  in  nine  experiments  was  51  beats 
per  minute.  Cook  and  Pembrey^  have  noted  an  increase 
in  pulse-rate  up  to  180  per  minute.  After  the  maximum 
rate  has  been  reached  there  is  not  much  variation  during 
the  period  of  activity.  After  cessation  of  muscular  effort, 
there  is  a  fall  to  normal  and  rarely  to  subnormal,^  much 
less  rapid  than  the  fall  of  blood-pressure.  After  pro- 
longed, severe  exercise,  the  pulse-rate  may  remain  above 
normal  for  a  long  time  and  in  some  cases  there  may  be  a 
secondary  rise  which  appears  to  be  due  to  a  reflex  effort  to 
improve  the  negative  phase  of  low  pressure. 

The  recovery  to  normal  is  most  rapid  in  well-trained 
men  whereas  in  the  untrained,  severe  exercise  causes  a 
persistently  rapid  pulse  often  irregular,  which  may  remain 
so  for  some  time. 

*  Amer.  Jour.  Physiol.,  1913,  xlv,  p.  429.  *  Lowsley,  loc.  cit. 


PHYSICAL   FITNESS,    EXERCISE   AND   ATHLETICS  179 

10.  Since  after  prolonged  exercise  the  systolic  pressure 
falls  more  rapidly  than  the  diastolic,  there  results  a  period 
of  small  pulse  pressure.  At  the  time  of  this  small  pulse 
pressure  albumin  is  frequently  found  in  the  urine.  An 
albuminuria  coincident  with  low  pressure  after  exercise 
has  been  described  by  Erlanger  and  Hooker. 

11.  The  more  rapid,  vigorous,  fatiguing  and  exhausting 
the  exertion,  the  more  probable  the  subnormal  phase  and 
the  longer  its  duration.^  A  subnormal  phase  frequently 
occurs  if  the  exercise  be  short  and  exhausting,  as  well  as 
when  moderate  but  continued  over  a  longer  period  of 
time.  Lowsley  also  suggests  that  the  duration  of  the 
subnormal  phase  may  be  taken  as  a  very  fair  index  of  the 
strain  on  the  circulatory  system  and  he  has  come  to  be- 
lieve that  a  subnormal  phase  of  less  than  an  hour  may  be 
considered  as  safe,  while  if  it  persists  for  more  than  two 
hours,  it  is  a  sign  that  the  margin  of  safety  has  been 
exceeded. 

12.  Long  distance  running  and  exhausting  boat  races 
and  other  similar  forms  of  exercise  are  a  serious  strain  upon 
the  heart  which  is  indicated  by  a  prolonged  period  of 
subnormal  pressure  or  negative  phase. 

13.  In  a  hypertrophied  heart,  the  seat  of  a  systoUc  mur- 
mur, not  due  to  valvular  lesions,  severe  athletic  contests 
may  cause  the  murmur  to  temporarily  disappear,  or  on  the 
other  hand,  systolic  murmurs  may  appear  in  a  heart  in 
which  none  were  present  before  the  contest  (Barach). 

14.  After  prolonged  and  severe  contests,  arrhythmia  may 
appear.  This  is  best  explained  by  Shumacher  and  Mid- 
dleton  as  being  the  result  of  mechanical  injury  to  the  con- 

1  E.  O.  Otis,  Amer.  Jour.  Med.  Set.,  February,  1912,  cxliii,  No.  2. 


180  BLOOD-PRESStTBE 

ducting  apparatus;  that  is,  to  fibrillary  tears  in  the 
myocardium.^ 

15.  By  the  telerontgen  method,  C.  S.  Williamson^ 
has  demonstrated  that  (a)  the  normal  heart  responds  to 
any  exercise  within  its  power  by  a  diminution  in  size; 
(6)  about  50  per  cent,  of  pathologic  hearts,  which  are  in 
good  compensation,  respond  to  exercise  within  their 
power,  by  a  diminution  in  size;  (c)  approximately  50  per 
cent,  of  the  pathologic  hearts,  which  manifest  but  a  low 
grade  of  broken  compensation,  respond  in  the  same  manner 
by  some  diminution  in  size. 

Permanent  Result  of  Prolonged  Muscular  Exercise  and 
Cardiac  Overstrain. — There  is  less  argument  concerning 
the  ultimate  result  of  over-exertion  on  the  heart  than  upon 
the  immediate  effect  of  physical  exertion.  The  following 
points,  however,  seem  to  be  clearly  established: 

1.  Severe  exertion  from  violent  and  prolonged  efforts 
may  reach  a  point  beyond  the  capacity  of  the  heart  muscle 
to  produce  a  complete  systole.  This  results  in  the  typical 
symptoms  of  acute  cardiac  dilatation.  The  prognosis 
here  depends  upon  whether  the  heart  was  previously  sound 
or  not.^  The  weakened  condition  of  the  cardiac  muscle  is 
shown  after  the  cessation  of  effort  by  its  inability  to  return 
to  its  normal  size. 

2.  Infectious  diseases  especially  tend  to  weaken  the 
myocardium.  For  this  reason,  severe  athletic  contests 
should  be  avoided  by  those  suffering  with,  or  convalescent 


iL.  Shumacher  and  W.  S.  Middleton,  Jour.  A.  M.  A.,  Apr.  11,  1914, 
Ixu,  No.  15,  p.  1136. 

2  Am.  Jour.  Med.  Sci.,  1915,  cxlix,  No.  4. 

3  K.  Blandenburg,  Med.  klin.,  Sept.  3,  1914,  x,  37. 


PHYSICAL   FITNESS,    EXERCISE    AND    ATHLETICS  181 

from,  acute  infectious  diseases,  even  often  mild  cases  of 
tonsillitis  and  grippe. 

3.  Immoderate  physical  efforts  lead  to  hypertrophy  of 
the  heart.  Athletic  training  leads  first  to  physiologic 
hypertrophy,  but  if  prolonged  and  overdone  it  leads  to 
hypertrophy  plus  dilatation.  The  degree  is  variable  and 
may  frequently  lead  to  marked  valvular  insufficiency.^ 

4.  Functionally,  the  hypertrophied  heart,  even  when 
dilated  and  giving  distinct  evidence  of  valvular  insufficiency 
may  prove  more  fitted  to  carry  the  man  through  a  severe 
athletic  contest  than  a  normal  heart  would  be.  On  the 
other  hand,  acute  cardiac  dilatation  occurs  more  frequently 
in  athletes  and  men  habituated  to  severe  muscular  strain 
than  in  average  men,  and  the  ultimate  effects  are  more 
prolonged  and  severe.- 

5.  Hearts  known  to  be  diseased  may  respond  in  the 
normal  manner,  as  shown  by  a  reduction  in  size  after  the 
cessation  of  moderate  exertion,  while  hearts  that  give  a 
distinct  systolic  murmur  may  withstand  a  Marathon  race 
better  than  hearts  which  are  apparently  nearer  normal.' 

6.  There  is  reason  to  believe  that  for  normal  human 
activities  an  ''athletic  "  heart  is  distinctly  disadvantageous.^ 

7.  Experience  teaches  that  much  good  can  be  secured  by 
careful  examination  of  the  heart  before  and  after  moderate 
exercise,  of  all  those  who  desire  to  enter  severe  athletic 
contests.  Failure  to  obtain  a  normal  reaction  should  bar 
anyone  from  such  contests.  Even  those  apparently  stand- 
ing such  contests  well  should  have  the  heart  and  blood- 

^  Shumacker  and  Middleton,  loc.  cit. 

2  Shumacker  and  Middleton,  loc.  cit. 
2  Barach,  loc.  cit. 

*  Shumacker  and  Middleton,  loc.  cit. 


182  BLOOD-PRESSURE 

pressure  examined  at  frequent  intervals  during  training, 
to  detect  possible  overstrain.  Continued  overstrain  even 
when  slight  may  weaken  a  normal  heart  muscle  instead  of 
strengthening  it.  This  appears  to  be  particularly  true 
among  young  boys  (of  immature  development)  who  have 
been  found  to  develop  persistent  cardiac  changes  the 
result  of  prolonged  overstrain. 

8.  Carefully  collated  statistics^  show  that  athletes  die 
from  the  following  diseases  in  their  order  of  frequency: 
cardiac  disease,  tuberculosis,  typhoid  fever,  pneumonia 
and  Bright's  disease. 

1  R.  E.  Coughlin,  Med.  Rec,  Aug.  8,  1914,  Ixxxvi,  No.  12. 


CHAPTER  XI 
BLOOD-PRESSURE  IN  CHILDREN 

Reference  to  the  normal  blood-pressure  values  in  children 
has  already  been  made  in  the  section  devoted  to  normal 
blood-pressure  and  the  factors  causing  its  variation,  so  that 
further  discussion  of  this  portion  of  the  subject  is  omitted 
here  (see  page  115). 

In  studying  the  difference  between  the  average  pulse 
pressure  in  children  and  in  adults,  G.  S.  Melvin  and  J.  R. 
Murray,^  employing  a  Pachon  oscillometer  with  an  8-cm 
arm-band,  found  an  average  variation  of  about  10  mm., 
giving  their  average  as  46  mm.  in  adults  as  compared  with 
35.7  mm.  in  children.  This  is  in  close  accord  with  the 
at  present  accepted  belief  that  the  pulse  pressure  is  equal  to 
about  one-third  the  systolic  pressure. 

The  same  factors  which  influence  blood-pressure  from 
time  to  time  in  adults  act  with  even  greater  force  upon 
blood-pressure  in  children. 

It  is  generally  believed  that  all  things  being  equal  the 
weight  and  size  of  the  child,  rather  than  the  exact  age,  is 
the  important  factor  in  determining  the  actual  systolic 
pressure  level. 

Orthostatic  Albuminuria  in  Children. — The  occurrence 
of  this  condition  and  its  relation  to  and  effect  upon  blood- 
pressure  is  of  considerable  interest  and  importance  to  the 

1  Brit.  Med.  Jour.,   Apr.  17,  1915,  1,  2833. 
183 


184  BLOOD-PRESSURE 

pediatrician,  as  here  the  blood-pressure  test  will  serve  to 
differentiate  this  type  of  urinary  disturbance  from  those  of 
more  serious  import.  In  this  connection  the  occurrence 
of  this  type  of  albuminuria  is  rather  interesting.  Thus 
K.  Bugge^  examined  over  a  thousand  school  children  and 
found  albumin  present  in  14.9  per  cent,  in  which  it  had  no 
relation  to  cardiovascular  or  renal  conditions.  In  dem- 
onstrating the  effect  of  physical  exercise  upon  this 
condition  Bugge  was  able  to  demonstrate  the  development 
of  transient  albuminuria  in  20  per  cent,  of  healthy  boys 
after  gymnastic  exercise. 

This  type  of  albuminuria  is  sometimes  seen  in  convales- 
cents and  as  an  accompaniment  of  cardiovascular  weakness 
in  the  presence  of  low  blood-pressures,  and  is  here  probably 
a  reflection  of  an  abnormal  reaction  of  the  vasomotor 
relations  of  the  kidneys. 

Bass  and  Wessler's^  observations  show  that  the  blood- 
pressure  of  children  suffering  from  orthostatic  albuminuria 
differs  but  little  from  that  of  normal  children,  in  spite  of 
an  apparent  vasomotor  insufficiency,  which  many  of  these 
children  show. 

Blood-pressure  reactions,  both  in  the  upright  and  in 
the  recumbent  postures  and  after  exercise,  revealed  no 
characteristic  anomaly.  Nor  were  they  able  in  any  way 
to  correlate  the  blood-pressure  findings  with  the  findings 
in  regard  to  the  size  and  strength  of  the  heart  or  the  pulse 
rate.  They  do  not  believe  that  children  with  orthostatic 
albuminuria,  accompanied  by  cardiovascular  symptoms, 
can  be  differentiated  by  means  of  blood-pressure  tests. 

1  Norsk.  Magazin.  J.  Legevid,  December,  1914,  Ixxiv,  12. 

'  H.  H.  Bass  and  H.  Wessler,  Arch.  Int.  Med.,  January,  1914,  xii,  1. 


BLOOD-PRESSURE    IN    CHILDREN  185 

Pneumonia. — The  fact  that  the  symptoms  of  death  of 
children  from  pneumonia  are  largely  those  of  vasomotor 
failure,  makes  the  study  of  this  reaction  of  particular 
importance.  Howard  and  Hoobler^  have  studied  the 
effect  of  fresh  air  on  patients  with  acute  pneumonia.  They 
j&nd  that  there  is  always  a  rise  in  blood-pressure  follow- 
ing removal  from  a  warm  well-ventilated  ward  to  the  cold 
balconies  of  Bellevue  Hospital.  This  rise  is  apparent  at 
the  expiration  of  a  half  hour  or  more,  after  removal,  and 
reaches  its  maximum  only  after  about  two  hours,  remain- 
ing constant  thereafter,  even  for  thirty  hours,  and  there 
was  noted  no  tendency  for  the  pressure  to  fall  as  if  from 
exhaustion  by  the  effort.  Upon  return  to  the  warm  well- 
ventilated  ward  a  fall  is  apparent  in  from  fifteen  to 
twenty  minutes,  usually  reaching  its  lowest  point  in  an 
hour,  when  it  remains  unless  influenced  by  the  course 
of  the  disease,  by  stimulation  or  by  a  return  to  out-of- 
doors.  They  concluded  that  this  rise  of  10  or  15  mm. 
of  mercury  was  due  to  the  effect  of  the  cold  air  upon  the 
skin  of  the  face  and  on  the  nasal  mucous  membrane,  and 
not  to  the  purity  of  the  air. 

Acute  Nephritis. — Lenox  Gordon  reports  nine  cases  of 
acute  nephritis  in  all  of  which  the  blood-pressure  was 
found  to  be  above  normal.  In  some  cases  this  elevation 
is  marked,  becoming  of  distinct  diagnositc  value,  as  in 
no  other  disease  of  childhood  is  there  to  be  found  such  a 
marked  rise  in  pressure.  As  in  adults,  the  pulse  pressure 
has  a  tendency  to  be  increased,  owing  to  defective  elimina- 
tion  and   the   consequent   retention   of   toxic   substances 

^  J.  Howard  and  B.  R.  Hoobler,  Am.  Jour.  Dis.  of  Children,  May,  1912, 
iii,  5. 


186  BLOOD-PRESSURE 

which  directly  affect  the  elasticity  of  the  arterial  walls  and 
the  permeability  of  the  capillary  system. 

The  frequent  occurrence  of  general  edema  in  this  disease 
calls  attention  to  the  importance  of  the  element  of  error 
introduced  into  pressure  readings  made  through  tissues 
where  edema  exists. 

The  Sphygmomanometer  in  Asphyxia  Neonatorum. — 
Ballard^  speaks  highly  of  the  value  of  the  sphygmoman- 
ometer as  a  means  of  detecting  the  persistence  of  the 
fetal  heart  beats  in  babies  born  in  asphyxia.  He  cites  four 
cases,  in  which  neither  the  radial  pulse  nor  the  heart  beat 
could  be  detected,  and  yet  in  which  the  apparatus  demon- 
strated slow  brachial  pulsations. 

» P.  Ballard,  Presse  Medicate,  1913,  Mar.  22,  No.  26. 


CHAPTER  XII 

ACUTE  INFECTIONS 

In  the  study  of  infectious  diseases,  the  routine  use  of 
the  blood-pressure  test  offers  an  almost  unlimited  field  of 
usefulness,  which  in  the  light  of  present  knowledge,  no 
physician  can  afford  to  neglect.  Naturally  this  test  offers 
little  in  the  way  of  diagnosis,  but  for  progno'sis  and  as  a 
guide  to  treatment  it  becomes  a  constant  and  a  most 
reliable  aid. 

TOXEMIA    AND    BLOOD-PRESSURE  i 

As  a  general  rule,  in  acute  infections  in  a  robust  individ- 
ual, where  the  onset  is  sudden,  there  is  noted  an  early  rise 
in  systolic  pressure  amounting  to  not  more  than  10  or  15 
mm.  Hg.  During  the  course  of  the  invasion,  as  the  toxemia 
develops,  there  is  a  gradual  fall  in  the  systolic  pressure  level, 
in  which  the  diastolic  participates,  usually  to  less  extent, 
the  result  being  a  narrowing  of  the  pulse  pressure.  As 
convalescence  advances  there  is  a  gradual  return  to  normal 
values.  The  degree  of  depression  and  the  rapidity  of  the 
return  of  the  convalescent's  pressure  to  normal  will  be 
influenced  by  (a)  the  duration  of  the  disease,  (6)  the 
profoundness  of  the  toxemia,  and  (c)  vitaUty  and  resist- 
ance of  the  patient.  The  depression  is  both  marked  and 
prolonged  in  typhoid  fever  and  in  pneumonia. 

Complications  may  alter  the  picture  in  several  ways. 

Thus,  in  convalescence  from  prolonged  fevers,  when  the 

187 


188  BLOOD-PRESSURE 

patient  assumes  the  erect  posture,  the  systolic  pressure 
may  be  found  to  fall,  while  the  diastolic  may  remain  un- 
changed. This  reduction  in  pulse  pressure,  tends  to 
cerebral  anemia  which  reflexly  increases  heart  rate,  thereby 
causing  unnecessary  cardiac  strain.  This  probably  ex- 
plains the  cardiac  disturbances  seen  so  often  in  convalescents 
from  acute  infections  and  which  should  be  guarded  against 
by  frequent  blood-pressure  observations,  permitting  a 
gradual  return  to  physical  activity  only  when  indicated  by 
the  findings.  Even  late  in  the  convalescence  or  after 
apparent  return  to  normal,  physical  exertion  may  cause 
the  same  disturbance,  from  which  the  heart  may  not  re- 
cover for  weeks  or  even  months.  So  frequently  is  this 
condition  encountered  that  R.  N.  Willson^  has  said  that 
"we  may  state  that  there  occurs  probably  no  instance  of 
perfect  cardiac  recovery  from  an  acute  micro-organismal 
invasion." 

The  incidence  of  renal  irritation  or  of  an  acute  nephritis 
during  the  course  of  an  acute  infection  will  speedily  be 
accompanied  by  a  sharp  rise  in  systolic  pressure  even  before 
urinary  or  other  signs  appear. 

Violent  purging  and  diarrhea  will  accentuate  the  usual 
fall  seen  during  the  progressive  stages  of  acute  infections.^ 

Venous  pressure  tends  to  fall  coincidently  with  the 
systolic  during  the  active  febrile  stage,  unless  the  heart 
becomes  embarrassed,  when  the  venous  pressure  rises  and 
adds  an  additional  burden  to  the  already  laboring  heart. 

In  acute  infections  the  basis  for  application  of  the  test  is 
the  experimental  evidence  of  the  influence  of  bacterial 

1  Penn.  Med.  Jour.,  December,   1914,  Vol.  iii,   No.   12. 

2  Nelson  and  Hyland,  Jour.  A.  M.  A.,  Feb.  8,  1913,  Ix,  6,  p.  436. 


ACUTE    INFECTIONS  189 

poisons  and  toxemias  on  the  vasomotor  system.  Sajous^ 
has  brought  forward  a  theory  of  the  relation  of  the  adrenal 
gland  to  the  dangerously  low  blood-pressure  found  in  the 
terminal  stages  of  acute  infections,  especially  in  pneumonia 
and  typhoid  fever.  Sajous  quotes  Goldzicher  who  reaches 
the  conclusion  that  in  septicemia  the  appearance  of  low 
blood-pressure  is  to  be  ascribed  to  insufficiency  of  the 
adrenals.  This  relation,  if  found  to  be  the  true  explana- 
tion, when  generally  recognized  may  yield  a  rich  harvest 
of  recoveries. 

Methods  of  Study. — In  the  study  of  infectious  diseases, 
single  observations  are  valueless  because  of  the  lack  of 
normal  figures  for  comparison.  Careful  daily  observations 
should  be  made  and  recorded  and  if  the  pressure  tends 
toward  a  dangerous  hypotension,  the  periods  of  observation 
should  be  shortened  to  meet  the  requirement. 

PNEUMONIA 

The  danger  in  pneumonia  is  largely  cardiac.  The  blood- 
pressure  is  usually  low.  The  toxic  influence  upon  the 
vasomotor  mechanism  and  upon  the  heart  muscle  may  be 
such  that  this  organ,  in  its  weakened  state,  is  unable  to 
pump  strongly  enough  to  maintain  an  efficient  arterial 
pressure,  in  the  face  of  vasomotor  relaxation.  Unfor- 
tunately, we  are  not  able  to  depend  entirely  upon  the  blood- 
pressure  test  as  a  guide  to  prognosis  in  pneumonia.  Statis- 
tics are  not  in  accord.  It  also  appears  that  death  occurs 
sometimes  in  cases  showing  higher  pressure,  while  some 
recover  with  very  low  pressure,  so  that  a  low  systolic 
pressure  does  not  necessarily  always  have  fatal  import. 

^Monthly  Cyclo.  Med.,  December,  1911. 


190 


BLOOD-PRESSURE 


Other  factors  enter  here,  praticularly  the  previous  history 
and  personal  habits  of  the  case,  especially  addiction  to 
alcohol.  ^ 

Gibson^s  Rule. — So  called  because  first  formulated  by 
Gibson^  in  1908.     This  blood-pressure  pulse  ratio  has  been 

BLOOD  PRESSURE  CHART 


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Fig.  37. — Showing  close  relation  between  pulse  rate  and  blood-pressure 
and  application  of  Gibson's  rule.  .  Symptoms  of  collapse  developed  after 
crisis  and  continued  until  normal  relation  was  reestablished  during  con- 
valescence. 

the  subject  of  much  controversy  and  an  occasional  frank 
attack  Newburgh  and  Minot,^  nevertheless  the  bulk  of 
clinicians  adhere  to  it  and  find  value  in  its  application  (see 
Fig.  37).     This  so-called  rule  as  originally  stated  by  Gibson 

1 L.  H.  Newburgh  and  G.  R.  Minot,  Arch.  Int.  Med.,  July,  1914,  xiv,  No.  1. 

*  Edinburgh  Med.  Jour.,  January,  1908. 

*  Loc.  cit. 


ACUTE    INFECTIONS  191 

is  as  follows :  ''When  arterial  (systolic)  pressure  expressed  in 
millimeters  of  mercury  does  not  fall  below  the  pulse  rate 
expressed  in  beats  per  minute,  the  fact  may  be  taken  as  of 
excellent  augury  while  the  converse  is  equally  true."  No 
one  should  accept  this  statement  unconditionally,  for  there 
are  many  exceptions.  In  applying  the  rule  the  physician 
will  avoid  being  led  into  the  error  of  relying  entirely  on  it, 
by  giving  due  weight  to  such  other  factors,  as  the  violence 
of  infection,  an  alcoholic  history  or  not,  the  presence 
of  chronic  disease,  etc.  Also  the  mere  disturbance  of  this 
ratio  for  a  short  period  is  of  little  significance,  becoming 
important  only  when  the  ratio  persists  for  some  time  in 
the  face  of  stimulating  measures. 

Concerning  the  practical  value  of  this  test,  G.  A.  Gordon^ 
states  that  in  a  recent  series  of  cases  studied  by  him  there 
were  no  fatahties  among  those  whose  quotient  remained 
B.P.>P.R. 

Alex.  Lambert^  studied  forty-eight  cases;  of  these  twenty 
failed  to  maintain  B.P.  >P.R.  and  of  them  six  or  42  per 
cent,  died,  while  the  twenty-eight  in  whom  B.P.  >P.R., 
five  or  17.09  per  cent.  died.  Gundrum  and  Johnson^ 
report  observations  on  thirty  institutional  cases  between 
the  ages  of  eighteen  and  sixty,  twenty  of  whom  were  alco- 
holic. They  had  nine  deaths  (mortality  30  per  cent.) 
among  those  whose  systolic  blood-pressure  on  admission 
ranged  between  65  and  122  mm.  Hg.  with  a  pulse  of  68  to 
148. 

Eighteen  cases  maintained  B.P.  >P.R.   and    seventeen 

^  Edinburgh  Med.  Jour.,  January,  1910. 
^Jour.  A.  M.  A.,  Dec.  2,  1911,  Ivii,  23,  p.  1827. 

'  F.  F.  Gundrum  and  E.  E.  Johnson,  Calif.  State  Jour,  of  Med.,  May, 
1912,  X,  5. 


192  BLOOD-PRESSURE 

or  94  per  cent,  recovered  while  of  the  twelve  who  showed 
B.P.  <P.R.,  nine  or  75  per  cent.  died.  These  observers 
feel  that  they  are  greatly  aided  in  treatment  by  following 
the  rise  and  fall  of  pulse  pressure  and  systolic  pressure. 

Auscultatory  Sounds  as  Aids  to  Prognosis. — The  second 
and  third  phases  when  good  and  clear  are  considered  favor- 
able signs  in  pneumonia  as  they  indicate  heart  strength 
(see  page  99).  The  second  phase  is  the  one  most  quickly 
lost,  from  heart  weakening  in  pneumonia,  and  its  presence 
throughout  the  disease  is  therefore  a  good  sign. 

The  muffling  or  weakening  of  any  of  the  sounds  should  be 
looked  upon  with  suspicion  as  such  changes  indicate  a 
relaxation  of  peripheral  resistance  and  a  failing  heart;  the 
addition  of  arrhythmia  to  these  variations  is  a  further 
indication  of  the  same  adverse  change.^ 

Newburgh  and  Minot  noted  among  other  findings  that 
the  blood-pressure  curve  in  pneumonia  did  not  suggest  a 
failure  of  the  vasomotor  center,  which  conclusion  has  been 
amply  confirmed  experimentally  by  W.  T.  Porter.  Both 
were  able  to  demonstrate  that  it  was  not  the  vasomotor 
center  but  the  myocardium  itself  that  failed  in  fatal  pneu- 
monia. Even  more  convincing  are  the  microscopic  find- 
ings of  Willson  who  in  every  instance  was  able  to  detect 
myocardial  changes  due  either  to  a  toxemia  or  to  a  local 
infection. 

F.  Tice-  found  Gibson's  ratio  to  hold  good  in  88  per  cent, 
of  cases  and  considers  it  of  value  not  only  in  prognosis  but 
also  of  much  assistance  in  treatment,  where  it  is  a  valuable 
guide  to  the  administration  of  stimulants. 

lA.  A.  Howell,  Jour.  A.  M.  A.,  Ixii,  16,  Apr.  18,  1914. 
^Jour.  A.  M.  A.,  Mar.  27,  1915,  Ixiv,  13. 


ACUTE    INFECTIONS  193 

Normal  Pressure  Level  in  Pneumonia. — G.  M.  PiersoF 
followed  ten  cases,  three  of  whom  ran  an  average  pressure 
above  normal  throughout  the  disease,  four  maintained  a 
pressure  that  was  normal  for  the  age  of  the  individual, 
three  fell  below  during  the  active  stage  but  quickly  rose 
after  the  crisis  to  an  approximately  normal  level. 

Relation  of  Pressure  to  Crisis. — Piersol  has  seen  a  rise, 
in  a  woman  aged  fifty,  amounting  to  40  mm.  systolic  and 
30  diastolic  in  less  than  twenty-four  hours  after  crisis. 

In  mild  cases  there  is  not  much  change  at  the  crisis,  espe- 
cially in  young  adults,  although  pressure  will  usually  be 
lower  after  crisis  and  during  convalescence  than  during 
the  height  of  the  disease.  A.  Lambert^  has  not  noted 
any  sudden  fall  at  crisis,  but  a  gradual  return  to  normal 
in  the  cases  that  recover,  the  pulse  usually  diminishing  in 
frequency  before  the  blood-pressure  rises,  though  occa- 
sionally the  reverse  may  be  true. 

In  cases  where  neither  pulse  nor  fever  is  high,  but  the 
blood-pressure  very  low,  below  100,  with  B  P  >  P  R  the 
cases  recover,  but  in  these  cases  the  pressure  is  very  slow  in 
rising  and  these  hearts  should  be  carefully  watched  and 
guarded. 

In  cases  with  chronic  nephritis,  though  the  pressure  may 
remain  between  170  and  220  yet  the  patients  may  die. 

The  reading  of  blood-pressure  in  arteriosclerosis  and 
nephritis  does  not  give  a  clue  to  the  cardiac  conditions  and 
in  these  cases  Gibson's  ratio  does  not  hold.  Dyspnea  may 
cause  rise  in  blood-pressure,  the  pressure  level  is  also 
influenced  by  the  day  of  the  disease. 

1  hoc.  cit. 

2  Jour.  A.  M.  A.,  Dec.  2,  1911,  Ivii,  23,  p.  1829. 

13 


194  BLOOD-PRESSURE 

TYPHOID  FEVER 

All  authorities  agree  that  typhoid  fever  is  a  disease  of 
hypotension,  and  that  the  depression  in  sj^stolic  pressure 
appears  early,  and  is  progressive  (unless  interrupted  by 
complications)  throughout  the  active  progress  of  the 
disease;  further,  the  depression  of  pressure  persists  for  a 
relatively  long  time,  even  after  the  temperature  has 
returned  to  normal  and  the  patient  is  well  established  in 
convalescence.  The  preexistence  of  cardiovascular  or 
renal  lesions  will  modify  the  pressure  readings  and  when 
variations  from  the  usual  course  are  met  such  complica- 
tions should  be  suspected.  Even  in  these  cases  a  hypo- 
tension (but  with  readings  above  the  patient's  normal 
age  level)  may  be  demonstrated,  if  we  were  able  to  obtain 
a  knowledge  of  the  patient's  pressure  before  the  onset  of 
the  disease. 

Vasomotor  weakness  of  the  splanchnics  caused  by  the 
toxins  of  the  disease  is  usually  considered  to  be  the  cause  of 
the  pressure  depression. 

The  pressure  during  the  first  week,  when  cases  are  rarely 
seen  by  the  physician,  may  not  be  sufficiently  modified  to 
be  noticeable. 

Blood -pressure  Readings. — The  systolic  pressure  in 
typhoid  fever,  after  the  first  week  in  3''oung  adults,  will 
usually  register  below  100,  progressively  falling  until  the 
fourth  week,  when  it  usually  begins  to  ascend.^  Pressures 
of  85  and  90  systolic  are  not  uncommon,  while  a  systolic 
pressure  of  74  mm.  has  been  recorded  (Crile).  The  author 
as  a  matter  of  convenience,  and  as  an  aid  to  comparison, 
considers  that  the  pressure  in  typhoid  fever  averages  about 

'  Geo.  W.  Crile,  Jour.  A.  M.  A.,  xl,  1903. 


ACUTE   INFECTIONS  195 

110  mm.  Hg.,  during  the  first  week,  dropping  about  five 
points  per  week  during  the  next  three,  and  then  begins  to 
return  to  normal  as  convalescence  is  established. 

The  Diastolic  Pressure. — As  in  any  case  of  pressure 
variation,  the  diastolic  pressure  tends  to  follow  the  systolic, 
though  the  movement  is  usually  less.  This  results  in  a 
reduction  in  pulse  pressure,  which  is  present  during  the 
active  stages  of  the  disease  and  which  becomes  gradually 
lost  as  the  case  recovers,  to  return  temporarily  if  the  heart 
is  overstrained. 

The  blood-pressure  changes  in  typhoid  fever  are  so 
characteristic  that  in  obscure  cases  of  continued  fever,  a 
carefully  prepared  blood-pressure  chart  may  aid  in  clearing 
up  the  diagnosis.  Blood-pressure  readings  should  be  made 
as  regularly  and  frequently  as  are  the  pulse  and  tem- 
perature observations,  because  here,  as  in  any  other  con- 
ditions when  comparatively  rapid  alterations  are  to  be 
expected,  an  occasional  reading  is  valueless.  This  fact  is 
demonstrated  by  the  evidence  afforded  by  systematic  blood- 
pressure  records  which  may  call  attention  to  the  occur- 
rence of  such  complications  as  perforation  or  hemor- 
rhage. They  may  also  assist  in  an  early  diagnosis,  or  in 
demonstrating  the  effect  of  therapeutic  measures,  par- 
ticularly baths,  upon  the  cardiovascular  apparatus. 

Complications. — Perforation. — Crile^  and  Cook  and  also 
Briggs^  note  that  in  typhoid  fever  with  perforation  and 
peritonitis,  there  is  an  early  and  decided  rise,  which  is 
followed  by  a  fall  as  toxemia  increases.  This  was  found 
to  be  the  invariable  rule  by  Crile  in  twenty  surgical  patients. 

^Jour.  A.  M.  A.,  May  9,  1905. 

2  Johns  Hopkins  Hos.  Rep.,  Vol.  xi,  1903. 


196  BLOOD-PRESSURE 

A  sudden  rise  in  pressure  in  the  course  of  a  case  of 
typhoid  is  almost  positive  evidence  of  a  perforation,  though 
we  should  remember  that  a  stationary  pressure  is  no 
indication  that  the  catastrophe  has  not  occurred.^ 

Hemorrhage. — There  is  a  rapid  fall  in  blood-pressure 
without  the  initial  rise,  by  which  fact  it  may  be  separated 
from  the  preceding.  The  degree  and  rapidity  of  the  fall 
in  some  measure  indicates  the  extent  of  the  hemorrhage. 
The  pressure  tends,  upon  the  arrest  of  hemorrhage,  to 
return  rapidly  to  almost  the  level  noted  before  the  hemor- 
rhage occurred. 

Value  in  Treatment. — In  the  treatment  of  the  disease,  a 
study  of  blood-pressure  will  be  found  to  be  of  great  value. 
It  shows  the  best  mode  of  combating  the  circulatory  failure 
and  indicates  whether  our  efforts  should  be  directed  toward 
improving  peripheral  resistance,  or  toward  heart  stimula- 
tion, and  gives  a  clear  indication  whether  the  case  is 
receiving  too  little  or  too  much  fluid  for  the  capacity  of  the 
circulation. 

Nowhere  is  the  effect  of  stimulatory  measures  shown  to 
greater  advantage  than  by  the  changes  in  blood-pressure 
relations  shown  by  the  sphygmomanometer  through  records 
taken  before  and  after  a  bath. 

Secondary  and  Late  Effects  of  Typhoid  Infection  upon 
Blood -pressure. — Acute  infections  are  now  recognized  as 
among  the  most  frequent  as  well  as  the  most  insidious 
causes  of  arteriosclerosis  and  it  has  been  shown  that 
typhoid  fever  is  particularly  involved  in  the  early  produc- 
tion of  arteriosclerosis  (see  page  257). 

1  A.  L.  Sheppard,  Lancet,  May  11,  1907. 


ACUTE   INFECTIONS  197 

DIPHTHERIA 

The  effect  of  the  diphtheria  toxin  upon  muscular  tissue 
throughout  the  body,  and  upon  the  heart  muscle  in  par- 
ticular, has  long  been  a  grave  concern  of  the  practising 
physician,  heart  death  after  diphtheria  being  an  all  too 
frequent  sequela.  The  routine  estimation  of  blood-pres- 
sure therefore  becomes  an  important  prognostic  measure, 
particularly  in  this  disease. 

As  in  other  infections,  the  blood-pressure  tends  toward 
subnormal  during  invasion,  with  a  gradual  return  toward 
normal  during  convalescence. 

From  a  clinical  study  of  179  cases  of  diphtheria  Rolleston^ 
found  a  subnormal  pressure  in  sixty-three  cases  or  35  per 
cent.,  the  extent  and  duration  bearing  a  direct  relation 
to  the  severity  of  the  faucial  attack.  The  highest  readings 
were  found  during  the  first  and  the  lowest  during  the  second 
week.  The  normal  tension  was  usually  reestablished 
by  the  seventh  week.  Evidence  of  dyspnea  (partial 
asphyxia)  in  laryngeal  cases  caused  an  elevation  in  pressure. 
Tracheotomy  in  these  cases  was  followed  by  an  immediate 
fall  of  20  to  40  mm.  The  effect  of  serum  administration 
was  a  rise  in  pressure  in  40  per  cent,  of  cases.  Albuminuria 
did  not  cause  a  rise  in  pressure,  except  in  one  case  with 
uremia. 

In  studying  the  relation  of  blood-pressure  in  diphtheria 
to  myocardial  alterations  Bruchner^  examined  critically 
200  cases  of  this  disease.  He  found  that  mild  cardiac 
involvement  did  not  affect  the  normal  blood-pressure 
curve,  and  that  cases  with  irregular  blood-pressure  showed 

*  J.  D.  RoUeston,  Brit.  Jour,  of  Children's  Diseases,  October,  1911. 
»  Deutsche  med.  Wochen.,  Oct.  28,  1909. 


198  BLOOD-PRESSURE 

various  clinical  pictures.  Every  case  of  marked  fall  in 
pressure  was  associated  with  definite  signs  of  myocarditis. 
Falls  amounting  to  as  much  as  50  mm,  (Gartner's  tonometer) 
appeared  only  with  severe  myocarditis.  This  was  the 
greatest  drop  in  which  recovery  occurred.  A  steady  pro- 
gressive fall  in  pressure  was  present  in  the  fatal  cases.  In 
every  case,  with  one  exception,  marked  falls  in  pressure 
were  accompanied  simultaneously  by  signs  of  cardiac  in- 
voloement;  in  one  case  only  did  the  fall  precede  the 
cUnical  signs. 

Anaphylactic  Shock. — This  fortimately  rare,  although 
usually  fatal,  condition  is  believed  to  be  due  to  a  toxic 
constriction  of  the  bronchial  tree  which  results  in  a  con- 
dition of  strangulation.  As  far  as  known  we  believe  that 
this  process  is  primarily  accompanied  by  a  rise  in  pressure.^ 
This  rise  however,  is,  so  transient  that  it  is  rarely  observed; 
so  that  in  the  average  case,  if  pressure  readings  are  made, 
there  will  usually  be  found  a  marked  hypotension,  which 
is  the  usual  accompaniment  of  acute  cerebral  anemia  (see 
page  379). 

SCARLET  FEVER 

In  the  study  of  the  systolic  pressure  in  a  series  of  cases  of 
scarlet  fever,  Rolleston^  noted  that  the  extent  and  duration 
of  the  depression  was  usually  in  direct  relation  to  the 
severity  of  the  initial  attack,  and  that  while  the  greatest 
number  of  normal  readings  occurred  during  the  first  week, 
there  was  nevertheless  a  predominance  of  lowest  readings 
in  the  same  week.     The  great  majority  of  low  readings 

1  Auer  and  Lewis,  Jour.  A.  M.  A.,  1909,  Vol.  liii. 

-  J.  D.  RoUeston,  Brit.  Med.  Jour,  of  Children's  Diseases,  October,  1912 
Ix,  p.  444,  106. 


ACUTE   INFECTIONS 


199 


occurred  in  the  second  week,  while  normal  tension  was 
usually  reestablished  some  time  during  the  fourth  week. 
In  the  majority  of  cases  the  blood-pressure  was  lower  during 
convalescence  than  in  the  active  stage,  although  nothing 
of  a  characteristic  nature  regarding  the  relative  height  of 
the  pressure  during  the  acute  stage  as  compared  with 
the  nature  of  the  convalescence  has  been  found. 

With  the  exception  of  nephritis,  the  ordinary  com- 
plications have  little  if  any  effect  on  blood-pressure.  The 
chief  value  of  the  sphygmomanometer  in  scarlet  fever  is  in 
detecting  the  occurrence  of  marked  renal  irritation  as,  with 
the  development  of  an  acute  nephritis,  there  is  always  a 
sudden  and  marked  rise  in  arterial  pressure.  Buttermann^ 
has  observed  a  rise  of  more  than  50  mm.  within  twenty-four 
hours  after  such  an  occurrence. 

The  presence  of  marked  hypotension,  especially  if  ac- 
companied by  other  signs  of  vasomotor  insufficiency,  calls 
for  appropriate  measures  directed  toward  circulatory 
support. 

RoUeston's  Table  Showing  the  Number  of  Cases  in  Each  Week 
in  which  the  Highest  Readings  were  Recorded 


First 
week 

Second 
week 

Third 
week 

Fourth 
week 

Fifth 
week 

Sixth 
week 

Severe 

11 

17 
39 

1 
1 

4 

0 

4 
6 

1 

2 
3 

0 

2 
0 

1 

Moderate 

Mild 

0 
0 

1       67 

6 

10 

6 

2 

1 

An  unusual  range  of  systolic  blood-pressure  readings 
may  be  met  in  scarlet  fever  in  children;  thus  Rolleston 

^  Arch.  f.  klin.  Med.,  Ixxiv,  p.  11. 


200  BLOOD-PRESSURE 

has  noted  a  pressure  of  70  in  a  girl  aged  six  in  a  mild  attack, 
and  a  pressure  of  150  in  a  girl  aged  fifteen,  where  there 
were  no  signs  of  nephritic  involvement. 

The  average  case  will  run  between  105  and  75,  the  in- 
dividual readings  being  modified  as  in  the  normal,  par- 
ticularly by  the  age  factor.  The  occurrence  of  laryngitis, 
owing  to  the  respiratory  obstruction,  may  be  expected  to 
cause  a  rise  of  from  20  to  30  mm. 

CHOLERA 

Hypotension  is  the  rule.  Low  blood-pressure  during 
the  stage  of  collapse  is  a  valuable  guide  to  the  necessity  of 
transfusion.  The  blood-pressure  is  always  below  100. 
The  most  satisfactory  treatment,  or  the  one  most  likely  to 
combat  complications,  such  as  uremia,  is  administering 
the  intravenous  solution  of  adrenaUn.  By  this  means 
in  one  epidemic  the  death  rate  was  reduced  almost  one-half.^ 

In  cases  showing  very  low  pressures,  Rodger  and  Megraw^ 
consider  the  estimation  of  blood-pressure  of  great  value  in 
determining  the  frequency  and  quantity  of  saline  solution 
to  be  injected;  they  state  that  the  restoration  of  the 
circulation  thus  brought  about,  not  only  affords  great 
relief  to  the  patient  but  materially  aids  in  the  elimination 
of  toxins  through  the  kidneys  and  the  bowel. 

MALARIA 

In  chronic  malaria,  in  the  absence  of  complications,  the 
blood-pressure,  as  would  naturally  be  supposed,  is  usually 
low.  In  acute  cases  the  pressure  curve  follows  the  rise 
and  fall  of  the  fever,  being  high  during  the  chill  and  in  the 

*  Leonard   Rogers,    Therapeutic  Gazette,    Nov.    15,    1909. 
2  Indian  Med.  Gaz.,  March,  1908. 


ACUTE    INFECTIONS  201 

febrile  stage,  falling  as  the  sweating  process  begins,  and 
remaining  low  until  the  onset  of  the  next  rigor.  As  this 
phenomenon  is  the  natural  accompaniment  of  the  con- 
ditions with  which  they  are  associated,  irrespective  of  the 
cause,  the  findings  by  the  sphygmomanometer  have  but 
little  significance  in  this  disease. 

EPIDEMIC    CEREBROSPINAL    MENINGITIS 

G.  C.  Robinson^  found  that  elevated  intracranial  pressure 
is  almost  a  constant  phenomenon  in  epidemic  cerebro- 
spinal meningitis,  and  that  this  usually  is  accompanied 
by  elevated  blood-pressure.  This  rise  in  the  blood- 
pressure  appears  to  bear  some  relation  to  the  severity  of 
the  disease,  being  high  when  the  symptoms  are  severe  and 
low  when  mild,  and  during  convalescence.  Robinson's 
observations  in  reference  to  the  effect  of  lumbar  puncture 
are  not  in  accord  with  those  of  later  observers,  particularly 
Sophian.2  This  author  states  that  the  withdrawal  of 
fluid  in  meningitis  is  usually  accompanied  by  a  drop  in 
blood-pressure,  sometimes  quite  a  marked  one,  especially 
if  the  amount  of  fluid  withdrawn  be  great.  He  depends 
absolutely  upon  this  observation  as  a  guide  to  the  amount 
of  fluid  to  be  withdrawn  and  the  quantity  of  serum  to  be 
injected  in  the  treatment  of  this  disease.  Sophian's  pro- 
cedure is  as  follows:  Commencing  with  an  ordinary  ca^e 
with  a  systoHc  pressure  of  110  mm.  Hg.,  fluid  is  withdrawn 
until  a  fall  of  pressure  amounting  to  10  mm.  in  adults  and 
5  in  children  occurs.  If  the  pressure  begins  to  fall  quickly, 
the  rapidity  of  the  flow  should  be  reduced.     Occasionally 

1  Arch.  Int.  Med.,  May,  1910,  Vol.  B. 

2  Abram  Sophian,  Jour.  A.  M.  A.,  Mar.  23,  1912. 


202  BLOOD-PBESSURE 

there  is  no  fall  in  pressure  (there  may  even  be  a  rise)  and 
the  indication  here  is  to  remove  as  much  fluid  as  possible 
or  until  the  cerebrospinal  pressure  is  normal.  After  the 
fluid  has  been  withdrawn  the  serum  is  warmed  and  then 
slowly  injected.  When,  contrary  to  expectations,  the 
blood-pressure  continues  to  fall,  the  indication  here  is  as 
follows:  Beginning  with  a  10-mm.  drop  from  fluid  removal, 
the  injection  is  terminated  with  the  development  of  a 
total  drop  of  20  mm.  By  this  method  the  average  dose 
of  serum  is  smaller,  averaging  not  more  than  25  c.c.  in 
adults  and  in  children  in  proportion. 

Muscular  movements  and  pain  may  interfere  with  the 
correct  observation  of  pressure  while  the  presence  of 
internal  hydrocephalus  usually  causes  an  increased  systolic 
pressure. 

OTHER  ACUTE  INFECTIONS 

In  the  other  acute  infectious  diseases  there  is  little  to 
state  that  is  of  practical  importance  regarding  the  blood- 
pressure,  because  many  of  them  are  so  mild  as  to  have  no 
appreciable  effect  upon  arterial  tension,  and  also  because 
observations  as  far  as  they  have  been  made,  shed  very  little 
light.  In  general  it  may  be  stated  that  the  development 
of  toxemia  from  any  cause,  results  in  depression  of  the 
normal  pressure  curve  which  tends  to  return  to  normal 
with  relief  from  the  toxemia. 


CHAPTER  XIII 
CHRONIC  INFECTIONS 

TUBERCULOSIS 

Statistics  upon  blood-pressure  observations  in  tubercu- 
losis made  by  different  observers  show  wide  variations  in 
the  results  recorded,  though  they  agree  upon  two  points: 
first,  that  the  systohc  blood-pressure  is  lessened  when  this 
disease  is  active  and  that  it  becomes  progressively  lower 
as  the  disease  advances,  and  second,  that  it  rises  toward 
normal  as  the  process  is  arrested  and  the  disease  cured. 
The  first  of  these  points  is  exemplified  by  the  following 
statistics  which  have  been  collected,  tabulated  and  aver- 
aged by  Pottenger.^  These  observations  are  grouped  for 
comparison  according  to  recognized  divisions  into  first, 
second  and  third  stages,  and  are  as  follows: 

In  Strandgaart's  series^  the  systolic  pressure  averaged 
in  the 

First  stage 125  mm.  Hg. 

Second  stage 121  mm.  Hg. 

Third  stage 118  mm.  Hg. 

Burckardt,^  making  his  examinations  at  Basel,  found 
that  the  average  systolic  pressure  in  the 

First  stage 107.6  mm.  Hg. 

Second  stage 104.6  mm.  Hg. 

Third  stage 100.3  mm.  Hg. 

^N.  Y.  Med.  Jour.,  Aug.  31,  1912,  p.  418. 

'  N.  J.  Strandgaart,  Internal.  Zentralb.  f.  Tuberkulose,  1908,  p.  224. 
'  Zdtsch.  /.  Tuberkulose,  v,  p.  19,  viii,  pp.  465-8. 

203 


204  BLOOD-PRESSURE 

Ingersheim^  found  in  the 

First  stage 100.4  mm.  Hg. 

Second  stage 97.3  mm.  Hg. 

Third  stage 95.4  mm.  Hg. 

Pottenger-  examined  twenty  normal  persons  and  com- 
pared the  findings  with  those  in  135  tuberculous  patients 
divided  according  to  stages  of  the  disease.  The  average 
systolic  and  diastolic  pressures  were  as  follows: 

Systolic  Diastolic 

20  normal  individuals 120  108  mm.  Hg. 

11  patients  in  first  stage 106  78  mm.  Hg. 

21  patients  in  second  stage 108  81  mm.  Hg. 

103  patients  in  third  stage 103  75  mm.  Hg. 

Thus  we  have  average  blood-pressure  readings  as  follows : 

First  stage from  100.4  to  125  mm.  Hg. 

Second  stage from     97.3  to  121  mm.  Hg. 

Third  stage from     75.4  to  118  mm.  Hg. 

That  a  depression  in  systolic  level  is  an  early  sign  of 
tuberculosis  is  accepted  by  most  observers.  The  impor- 
tance of  this  point  has  been  emphasized  by  Cook  who  makes 
the  following  significant  statement:  "When  low  blood- 
pressure  is  persistently  found  in  individuals  or  in  families 
it  should  put  us  on  our  guard  for  tuberculosis,"  and  Haven 
Emerson,  3  dwells  upon  the  fact  that  hypotension  should 
be  sought  for  just  as  carefully  in  a  physical  examination 
as  we  customarily  search  for  pulmonary  signs.  Many 
cases  of  so-called  idiopathic  low  pressure  will  be  found  later 
to  develop  signs  of  pulmonary  involvement  so  that  hypo- 
tension,   when   otherwise   unexplained,    should   suggest   a 

^Zeitsch.  f.  Tuberkulose,  viii,  p.  467. 
^Arch.  Int.  Med.,  October,  1909. 
KA.rch.  Int.  Med.,  April,  1911. 


CHRONIC    INFECTIONS 


205 


careful  examination  for  tuberculosis,   particularly  of  the 
lungs. 

N.  J.  Strandgaart^  believes,  with  others,  that  a  low  pres- 
sure may  help  to  differentiate  tuberculosis  in  doubtful  cases, 


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FiQ.  38. — Male.  Married,  aged  thirty-seven.  Chronic  phthisis.  Has 
already  had  several  hemorrhages,  there  is  a  small  cavity  in  right  upper  lobe. 
Periods  of  depression  of  systolic  occurred  coincidently  with  exacerbations 
of  the  disease.  The  observation  at  (A)  was  made  after  the  patient  had 
suffered  a  severe  attact  of  grippe. 

Between  periods  A  and  B  condition  has  improved  in  spite  of  an  attack  of 
grippe  and  weight  increased  9  lb.  Tuberculin  treatment  begun(B).  Last 
examination;  weight  stationary,  and  temperature,  pulse  and  respiration 
normal,  no  cough,  appetite  and  stomach  in  good  condition. 


and  that  it  will  show  whether  a  tubercular  process  is  active 
or  latent,  for  practically  all  authorities  have  agreed  that 
hypotension  is  present  in  tuberculosis,  that  it  progress- 

^  Hospitalstindende,  Oct.  16,  1907,  1,  42,  p.  1113. 


206  BLOOD-PRESSURE 

ively  increases  with  the  extension  of  the  process  and 
that  recovery  from  the  hypotension  indicates  the 
arrest  of  or  improvement  in  the  pulmonary  lesions 
(see  Fig.  38).  Return  to  normal  pressure  is  commonly 
found  in  those  who  are  cured,  as  a  continued  low  level 
appears  never  to  exist  in  the  presence  of  pulmonary  im- 
provement. 

In  spite  of  the  fact  that  a  lowered  systolic  pressure  is 
practically  always  the  accompaniment  of  an  active  pul- 
monary tuberculosis,  it  is  believed  that  the  degree  of 
involvement  does  not  necessarily  bear  any  relation  to  the 
systolic  level,  so  that  observations  do  not  throw  any  special 
light  in  this  direction.^ 

This  variation  in  systolic  depression  in  active  cases  has 
been  ingeniously  explained  by  Pottenger^  who  states  that 
we  have  several  modifying  factors  which  are  opposed  to 
the  generally  depressive  effect  of  the  toxemia  on  the  vas- 
cular tonus  and  on  the  vasomotor  centers.  Thus,  early 
in  the  disease  there  is  an  increased  number  of  heart  beats 
which  results  in  an  hypertrophy  of  the  right  ventricle; 
followed  later,  when  pulmonary  pressure  is  increased,  by  an 
augmentation  of  strength  of  the  right  ventricle,  a  condition 
which  is  maintained  as  long  as  the  muscle  is  able  to  meet 
the  additional  strain.  Furthermore,  the  toxins  of  the 
disease,  which  continue  to  circulate,  directly  affect  the 
arterial  wall  and  bring  about  a  condition  of  generalized 
arterial  fibrosis,  so  that  the  longer  the  disease  exists  the 
greater  the  development  of  this  condition.  The  relation 
of  arteriosclerosis  to  tuberculosis  is  conclusively  shown  in 

^L.  S.  Peters,  Arch.  Int.  Med.,  August,  1908. 
2  Loc.  cit. 


CHRONIC    INFECTIONS 


207 


the  study  of  162  patients  where  the  following  results  were 
obtained : 


Condition  of  radials 


Duration  of  the  disease 


Less  than 
one  year 


One  to  two 
years 


More  than 
two  years 


Palpable 

Non-palpable . 


14 
14 


20 

21 


60 
33 


The  effect  of  altitude  upon  systolic  pressure  in  the  tuber- 
culous has  been  the  subject  of  investigation  by  a  number  of 
observers,  and  the  consensus  of  opinion  is  generally  that 
at  an  altitude  of  6000  ft.^  the  blood-pressure  is  increased  as 
compared  with  the  pressure  in  tubercular  cases  seen  at 
sea  level.  This  opinion  is  not  accepted  by  F.  C.  Smith^ 
who,  after  a  careful  series  of  observations  upon  groups 
of  both  normal  and  tuberculous  individuals,  found  the 
effect  of  altitude  on  the  systolic  blood-pressure  in  the 
tuberculous  to  be  insignificant.  He  believes  that  the  effect 
of  the  change  has  been  overestimated,  and  that  when  due 
allowance  had  been  made  for  disturbing  factors,  there  was 
nothing  observed  by  him  to  show  that  an  altitude  of  6230 
ft.  has  any  pronounced  influence  upon  this  phenomenon. 

Prognosis. — From  a  prognostic  standpoint  blood-pressure 
findings  are  of  great  value  in  tuberculosis  for,  although 
there  is  no  relation  between  the  degree  of  involvement  and 
the  systolic  level,  there  is  a  constant  relation  between  the 
degree  of  toxemia  and  the  blood-pressure.  Emerson^ 
believes  that  we  can  place  as  much  dependence  upon  altera- 

^  Peters  and  Bullock,  Arch.  Int.  Med.,  October,  1913,  xii,  No.  4. 
2  Jour.  A.  M.  A.,  May  29,  1915,  Ixiv,  22. 
2  Loc.  cit. 


208  BLOOD-PRESSURE 

tions  in  blood-pressure  as  we  now  do  upon  studies  of  the 
pulse  and  temperature.  It  must  not  be  forgotten,  in  this 
connection,  that  a  study  of  the  diastolic  pressure  is  of 
equal  importance,  and  that  both  in  tuberculous  suspects, 
and  during  the  course  of  the  disease,  changes  in  pulse 
pressure  are  most  significant,  not  only  as  indicating  the 
degree  of  the  toxemia  but  also  as  showing  the  effect  of 
therapeutic  measures  upon  the  cardiovascular  system. 

In  order  to  determine  the  relation  of  blood-pressure  to 
prognosis  Strandgaart^  studied  the  pressures  in  174  adults 
and  163  children  who  were  cured  or  materially  improved. 
These  showed  an  average  systolic  pressure  of  125  mm. 
Hg,  as  compared  with  234  patients  who  were  moderately  or 
not  at  all  improved  who  showed  an  average  of  121,  while  in 
twenty-one  adults  and  thirteen  children  in  whom  the 
disease  followed  a  progressive  course,  seventeen  of  whom 
succumbed,  the  average  was  108  mm.  Hg.  In  each 
group  there  was  a  wide  range  of  blood-pressure  in  in- 
dividual cases,  but  the  general  average  of  125  mm.  Hg.  in 
the  first  and  108  mm.  Hg.  in  the  last  group  are  very 
significant. 

Theory  of  Cause  of  Reduced  Pressure. — It  is  probable 
that  in  tuberculosis  as  in  other  infections,  the  systolic 
depression  is  due  to  the  effect  of  the  circulating  toxins  of 
the  disease  affecting  the  arterial  coats,  cardiac  nutrition 
and  the  vasomotor  centers.  It  has  also  been  suggested 
that  the  adrenals  are  in  close  relation  to  the  hypotension, 
although  Sezary-  investigating  this  possible  factor,  was 
unable  to  find  any  relation  between  the  state  of  the  supra- 

^  1907  reference. 

*  Arch,  des  maladie  du  coeur,  February,  1910,  iii,  2. 


CHRONIC   INFECTIONS  209 

renal  glands  and  the  low  pressure  found  in  tuberculosis,  and 
in  proof  cites  a  number  of  cases,  examined  at  autopsy, 
where  there  was  almost  complete  destruction  of  these 
glands  and  yet  which  during  life  showed  a  relatively  high 
blood-pressure. 

Hemorrhage. — During  the  earlier  studies  of  the  systolic 
blood-pressure  in  tuberculosis,  most  authorities  call  at- 
tention to  a  period  of  increased  pressure  preceding  or  ac- 
companying hemoptysis  in  patients  previously  showing 
hypotension.  Recently,  however,  Smith  ^  carefully  studied 
the  systolic  readings  in  a  series  of  cases  having  pulmonary 
hemorrhage,  as  compared  with  an  equal  number  of  cases 
who  were  free  from  this  complication,  from  which  he 
concludes  that  there  is  nothing  found  to  support  the 
contention  that  hemoptysis  is  more  likely  to  occur  in  those 
with  a  high  systolic  pressure. 

Accidental  Complications. — It  is  generally  believed  that 
the  intercurrent  development  of  an  arthritis  or  of  diabetes 
may  alter  the  blood-pressure  picture  by  causing  a  normal 
or  an  elevated  systolic  level  to  develop.  It  should  also  be 
borne  in  mind  that  the  presence  of  an  old  nephritis  will 
affect  the  readings  and  will  usually  cause  the  systolic 
pressure  to  be  above  normal,  although  the  elevation  of 
pressure  does  not  reach  the  level  that  would  ordinarily 
be  expected  from  the  degree  of  kidney  involvement.  The 
incidence  of  intercurrent  acute  infections  has  no  effect 
upon  the  systolic  pressure,  neither  has  the  administration 
of  alcohol  in  normal  medicinal  amounts.  Hyperalimenta- 
tion is  considered  by  Strandgaart  to  be  a  cause  for  a  rise 
in  systolic  pressure,  and  for  this  reason  he  urges  often  re- 

^  Loc.  dt. 
14 


210  BLOOD-PRESSURE 

peated  determinations  of  blood-pressure  as  a  guide  for  the 
proper  forced  feeding  of  tuberculous  cases.  The  usual 
efifect  of  a  change  from  warm  to  cold  air  is  to  produce  a 
rise  in  systolic  pressure  and  Hoobler^  has  found  that  the 
more  advanced  the  disease,  in  cases  treated  within  doors, 
the  lower  the  pressure  will  be  and  that  a  demonstrable 
increase  in  systolic  pressure  occurs  with  transfer  to  the 
open  air. 

Efifect  of  Exercise  on  the  Tuberculous. — A  valuable 
and  most  complete  study  of  the  effect  of  exercise  upon 
tuberculous  patients  has  been  made  by  L.  S.  Peters  and 
E.  S.  Bullock.  2  A  definite  plan  was  outlined  and  careful 
study  and  accurate  records  made.  Six  men  were  used. 
Three  were  excellent  cases  both  pulmonarily  and  physically, 
two  fairly  arrested,  far  advanced  cases;  and  one  a  new  re- 
cruit, with  normal  temperature,  but  poor  physical  con- 
dition. The  points  in  this  report  are  so  well  taken  and  the 
table  shows  so  graphically  the  results  obtained,  that  they 
are  copied  here  in  full. 

"All  six  were  started  with  a  fifteen  minutes'  walk  the  first 
day.  The  pressures  on  starting  of  the  three  able-bodied 
men  were  138,  132  and  148  respectively.  On  their  return 
the  pressures  were  138,  144  and  153.  After  an  hour's 
rest  the  readings  were  138,  142  and  158,  showing  that 
apparently  the  exercise  was  not  harmful.  The  two  fairly 
well  arrested,  far  advanced  cases,  started  out  with  pres- 
sures of  164  and  124,  returning  with  146  and  130,  and  after 
resting  164  and  118.  The  first  man  was  not  accustomed  to 
exercise  in  any  form,  as  is  clearly  shown  in  a  drop  of  18  mm. 

^  Amer.  Jour.  Dis.  of  Children,  1912,  iv. 
2  Med.   Rec,   Sept.    14,    1912,   p.   463. 


CHRONIC    INFECTIONS  211 

Hg.,  with  a  return  to  the  original  after  an  hour's  rest. 
The  over-exertion  in  the  second  man  is  evident,  for  we  find 
after  resting  that  there  is  a  drop  of  6  mm.  from  the  original 
reading  recorded  after  the  return  from  exercise." 

"The  new  recruit  started  with  146,  returned  with  138  and 
after  rest  his  reading  was  127.  The  over-exertion  in  this 
instance  is  well  illustrated  by  the  pressure  findings  and 
was  further  substantiated  by  the  marked  fatigue,  breath- 
lessness,  and  rapid  heart  action  of  the  individual.  This 
experiment  was  carried  on  for  a  period  of  six  days,  each 
day's  exercise  being  graded  by  the  previous  day's  results 
in  blood-pressure.  The  table  of  these  findings,  which 
we  here  append,  shows  at  a  glance  that  we  are  able  to 
control  the  readings  by  an  increase,  a  decrease,  or  a  repeti- 
tion of  the  exercise.  Whenever  a  man  showed  a  drop  of 
6  or  more  mm.  Hg.  after  rest  or  a  marked  drop  on  re- 
turning, even  though  this  disappeared  after  resting,  we 
decreased  the  exercise.  If  there  was  a  slight  drop  after 
returning  we  repeated  the  same  exercise  the  following  day 
or  until  we  maintained  an  even  standard,  when  the  walk 
was  increased.  It  is  interesting  to  note  that  in  one  of  the 
three  excellent  cases  the  pressure  remained  practically  the 
same  even  with  a  walk  of  one  and  a  half  hours,  and  later 
this  same  man  took  walks  of  two  hours  in  the  morning  and 
two  in  the  afternoon  with  no  change  in  pressure  and  no 
evil  results.  The  other  two  after  a  few  repetitions  were 
able  to  do  the  same." 

Improvement  in  subjective  symptoms  follows  the  efifect 
of  blood-pressure  elevation,  and  persists  if  the  pressure 
can  be  maintained  at  a  higher  level  than  that  existing  before 
such  treatment. 


212 


BLOOD-PRESSURE 


Case 
No. 

Blood-pressure 

Pulse 

Before 

After 

After 
rest 

Before 

After 

After 
rest 

Remarks 

1 

138 

138 
140 
142 
140 

142 

138 
141 
139 
140 
142 

138 

138 
150 
150 
140 
138 

140 

1st  day.  15  minute  walk. 

92 

98 
96 

88 

88 

98 

92 
106 

88 

88 

80 
76 
80 
76 

76 

2d  day.     Increased  to  30  minutes. 
3d  day.    Increased  to  40  minutes. 
4th  day.  Increased  to  1  hour. 
5th  day.  Increased  to  1  hour,  15 

minutes. 
6th  day.  Increased  to  1  hour,  30 

minutes. 

2 

132 
126 
126 
132 
126 
126 

144 
122 
135 
134 
130 
124 

142 
127 
126 
116 
126 
136 

1st  day.  15  minute  walk. 

74 
66 
78 
70 
73 

80 
76 
80 
80 
76 

68 

84 
72 
75 

2d  day.    Increased  to  30  minutes. 
3d  day.    Increased  to  45  minutes. 
4th  day.  Increased  to  1  hour. 
5th  day.  Cut  to  45  minutes. 
6th  day.  Repeated  1  hour  walk. 

3 

146 

142 

140 
132 
142 
138 

138 
124 

145 

145 

150 

146 

127 
132 

130 

142 

140 

142 

1st  day.      15  minute  walk. 

120 
120 
120 
116 
118 

120 
118 
120 
120 
120 

100 
96 
112 
108 
104 

2d  day.       Repeated     15    minute 

walk  at  slower  pace. 
3d  day.       Cut  to   10  minutes  at 

slow  pace. 
4th  day.     Repeated     10    minute 

walk. 
5th  day.     Repeated     10    minute 

walk. 
6th  day.    Increased  to  15  minutes. 

4 

148 
146 

145 

150 

145 
140 

152 
146 

142 

140 

140 
142 

158 
135 

146 

142 

158 
138 

1st  day.      15  minute  walk. 

2d  day.  Increased  to  30  min- 
utes. 

3d  day.  Repeated  30  minute 
walk. 

4th  day.  Increased  to  45  min- 
utes. 

5th  day.     Increased  to  1  hour. 

6th  day.  Increased  to  1  hour,  30 
minutes. 

88 

80 

80 

84 
76 

84 

80 

100 

80 
80 

72 

72 
72 

76 

80 

CHRONIC    INFECTIONS 


213 


Case 
No. 

Blood-pressure 

Pulse 

Before 

After 

After 
rest 

Before 

After 

After 
rest 

Remarks 

5 

164 

146 
140 
146 

144 

138 

146 

134 
150 
146 

144 

144 

164 
144 
138 
138 

152 

146 

This  man  unused  to  exercise. 

1st  day.      15  minute  walk. 

2d  day.       Cut  to  10  minutes. 

3d  day.       10  minute  walk. 

4th  day.  Increased  to  15  min- 
utes. 

5th  day.  Repeated  15  minute 
walk. 

6th  day.  Increased  to  25  min- 
utes. 

118 

100 

90 

110 

104 

120 
104 

98 
100 
104 

106 
100 
110 

100 

92 

6 

124 
115 

122 

115 

122 

115 

130 
114 

117 

110 

110 

114 

118 
110 

118 

115 

112 

114 

1st  day.      15  minute  walk. 

2d  day.  Repeated  15  minute 
walk. 

3d  day.  Increased  to  20  min- 
utes. 

4th  day.  Increased  to  30  min- 
utes. 

5th  day.  Increased  to  45  min- 
utes. 

6th  day.  Decreased  to  30  min- 
utes. 

110 
100 
100 

88 
96 

120 
100 
110 
110 
96 

108 
84 

100 
96 

88 

SYPHILIS 

The  syphilitic  heart  and  blood-vessels  show  clinically 
absolutely  nothing  characteristic,  nothing  which  might  not 
be  found  in  other  diseases.  Our  suspicions  will  be  aroused 
when  the  patient  is  below  the  age  of  senile  arteriosclerosis, 
when  the  involvement  is  essentially  aortic,  and  that  an 
incompetence,  when  the  symptoms  supervene  rather 
suddenly  and  are  not  accompanied  by  fever,  thus  excluding 
acute  endocarditis  from  any  other  cause.  ^ 

As  a  primary  cause  of  arteriosclerosis,   syphilis  is  too 


1  Geo.  Richter,  Med.  Rec,  Vol.  Ixxxii,  No.  14,  Oct.  5,  1912. 


214 


BLOOD-PRESSURE 


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Fia.  39. — Male.  Aged  forty-nine.  Specific  disease,  myocarditis  and  an 
old  syphilitic  and  alcoholic  hepatic  cirrhosis. 

Presented  for  examination  on  account  of  anasarca  involving  all  extremities, 
with  a  large  quantity  of  fluid  in  the  abdomen,  myocardium  and  pleurse. 
Urine  showed  albumen  very  large  amount  (3J^  Esbach),  occasional  casta 
and  red  blood  cells.  The  heart  sounds  were  extremely  difficult  to  analyze 
on  account  of  fluid.  Dyspnea,  cyanosis,  extreme  arrhythmia,  etc.,  indicated 
grave  heart  involvement.  Treatment  combined  specific,  with  infusion  of 
digitalis  and  was  most  unsatisfactory  on  account  of  the  patient's  insisting 
upon  traveling  in  spite  of  his  condition.  Between  A  and  B  patient's 
weight,  due  to  loss  of  fluid  fell  from  273  to  250;  and  from  B  to  C — from  250 
to  216K>  during  which  the  general  clinical  picture  very  much  improved. 
At  this  time  the  treatment  was  changed  to  a  modified  Niemeyer  pill,  and  later 
on  account  of  intolerance,  the  mercury  was  reduced  to  a  minimum.  Between 
C  and  D  conditions  became  very  much  worse  and  the  weight  returned  to 


CHRONIC    INFECTIONS  215 

well  known  to  demand  more  than  passing  consideration 
here.  In  any  history  this  disease  should  never  be  over- 
looked, but  should  be  given  due  consideration  as  a  pre- 
disposing cause  in  the  production  of  those  lesions  of  the 
cardiovascular  and  renal  systems  that  are  associated  with 
hypertension  (see  Fig.  39).  It  is  believed  by  many  that 
a  moderately  high  blood-pressure  which  can  be  traced  to  a 
previous  syphilitic  infection  is  more  amenable  to  treat- 
ment and  gives  more  satisfactory  results  than  continued 
high  pressure  from  other  causes.  This,  however,  remains 
to  be  proven.  In  the  meantime,  antisyphilitic  treatment, 
particularly  the  use  of  the  iodids,  should  be  vigorously 
carried  out. 

During  the  early  acute  stages  syphilis  acts  like  any  other 
general  infection,  in  that  it  is  usually  accompanied  by  a 
moderate  reduction  in  blood-pressure  with  some  narrowing 
of  the  limits  of  pulse  pressure.  These  changes  are,  as  a 
general  rule,  so  slight  that  they  need  not  be  considered  in 
caring  for  the  case;  therefore,  from  a  practical  standpoint, 
the  blood-pressure  in  acute  syphilitic  infection  is  of  little 
value. 


246.  At  E  the  addition  of  repeated  purges  to  the  digitalis  treatment 
again  reduced  the  weight  to  220.  At  F  the  weight  was  260  when  active 
treatment  was  again  instituted.  At  G  the  weight  was  reduced  to  234, 
when  there  were  no  special  complaints.  Dyspnea  not  a  factor,  the  color 
was  fair,  the  pulse  irregular  in  volume  with  a  fair  rhythm.  At  H,  a  severe 
infection  of  erysipelas  of  right  leg  followed  a  kick  by  a  horse.  Temperature 
105%  probably  contributing  to  the  extreme  pulse  pressure  record  at  this  time. 
At  /,  was  convalescent  and,  due  to  continued  rest,  cardiac  and  circu- 
latory conditions  were  excellent.  Subsequent  treatment  has  been  entirely 
cardiac.  The  average  systolic  and  pulse  pressure  indicates,  as  do  also  the 
patient's  symptoms,  that  his  condition  is  far  better  than  when  first  seen. 


CHAPTER  XIV 

BLOOD-PRESSURE  IN  METABOLIC,  NEUROLOGIC  AND 
MISCELLANEOUS  CONDITIONS 

The  material  contained  in  this  chapter  has  been  gleaned 
from  a  large  volume  of  recent  current  literature.  Its  value 
to  the  physician  will  depend  largely  upon  the  method 
of  its  application  in  relation  to  the  case  in  point,  and  will 
rather  be  corroborative  and  suggestive  than  distinctly 
diagnostic. 

Addison's  Disease. — Janeway  has  reported  two  cases 
of  unquestioned  Addison's  disease,  in  which  the  systolic 
pressure  tended  downward.  More  recently  Gibson^  re- 
ports very  low  pressures  in  his  series  of  cases.  Two  cases 
seen  by  the  author  showed  a  marked  degree  of  hypoten- 
sion. A.  Rendel  Short  (''New  Physiology")  discusses  the 
subject  from  the  physiologic  standpoint,  and  shows  that, 
if  the  suprarenal  veins  are  clamped  for  a  few  hours, 
thereby  preventing  the  entrance  of  adrenalin  secretion 
into  the  circulation,  the  blood-pressure  rapidly  falls.  As 
the  pathology  of  Addison's  disease  involves  a  degenera- 
tive process  of  the  adrenal  glands,  we  have  the  probable 
explanation  of  the  low  blood-pressures  found  in  this  disease. 
Improvement  in  subjective  symptoms  follows  efforts 
directed  toward  blood-pressure  elevation,  and  persist  if 
the  pressure  can  be  maintained  at  a  higher  level  than  that 
existing  before  such  treatment. 

1  Brit.  Med.  Jour.,  Dec.  10,  1910. 
216 


BLOOD-PRESSURE    IN    METABOLIC    CONDITIONS  217 

Aviation  Sickness. — In  the  Medical  Press  and  Circular 
for  August,  1911,  reference  is  made  to  a  communication  by 
Crouchet  and  Moulinier  to  the  French  Academy  of  Sciences, 
in  which  they  report  their  observations  upon  a  number  of 
aviators.  They  note  two  varieties  of  trouble  resulting 
from  flights  in  aeroplanes.  The  first  is  due  to  the  altitude 
attained,  and  depends  on  differences  in  atmospheric  pres- 
sure and  temperature,  and  to  changes  in  the  chemical  com- 
position of  the  air  found  at  high  altitudes. 

The  second  factor,  which  need  not  be  discussed  here,  is 
the  actual  physical  effort  put  forth.  They  consider  the 
rapidity  of  ascent  and  of  descent  as  most  important,  and 
recommend  a  reduction  in  the  speed  at  which  these  changes 
should  take  place.  The  effect  of  ascent  begins  to  be  shown 
when  a  height  of  1500  meters  (4500  ft.)  is  reached,  which 
causes  quick,  short  respiration  and  tachycardia.  There  is 
usually  a  sensation  of  headache  and  moderate  deafness. 
During  descent  there  is  a  sensation  of  discomfort  like  that 
which  accompanies  a  sudden  descent  in  an  elevator,  violent 
palpitation  and  great  noise  in  the  ears.  On  landing  the 
aviator  is  not  free  from  the  above  sensations  for  a  consid- 
erable time.  Respiration  quickly  returns  to  normal  but 
arterial  hypotension  which  was  found  in  most  cases  to  be 
quite  marked,  persisted  for  a  long  time  after  the  flight  was 
finished. 

Acute  Alcoholism. — According  to  Raff^  in  a  chronic 
alcoholic  acutely  inflamed  with  alcohol,  there  is  a  relative 
hypertension.  During  the  first  few  days  of  treatment 
(withdrawal  of  alcohol)  this  hypertension  persists  and  then 

^Deutsch.  Arch  f.  klin.  Med.,  1913,  cxii. 


218  BLOOD-PRESSURE 

there  is  a  gradual  return  to  normal  as  the  physical  con- 
dition of  the  case  improves. 

Cardiac  Asthma. — Attacks  of  sudden  asthma  occurring 
in  the  course  of  chronic  cardiovascular  and  renal  diseases 
are  the  direct  result  of  some  disturbance  in  the  pulmonary 
circulation,  probably  due  to  a  dilatation  of  the  right 
ventricle  and  a  rise  in  pressure  in  the  pulmonary  artery. 
This  results  in  a  condition  of  air  hunger,  in  which  defective 
alveolar  interchange  plays  an  important  part.  The  re- 
sulting condition  is  virtually  a  partial  asph3rxia  and  is 
accompanied  by  a  sharp  rise  in  systolic  pressure  (see  Fig. 
40).  Some  authors  even  go  so  far  as  to  state  that  this 
dyspnea  is  the  underlying  cause  of  hypertension  although 
this  is  probably  only  the  case  in  the  essential  or  true 
bronchial  asthma. 

Pulmonary  Edema. — It  is  believed  that  acute  pulmonary 
edema  is  associated  with  a  sharp  rise  in  systolic  pressure, 
although  we  have  no  knowledge  of  the  condition  of  the 
circulation  immediately  preceding  the  actual  filling  up 
of  the  lung  tissue  so  that  we  do  not  actually  know  whether 
the  rise  in  pressure  is  primary  or  secondary  to  the  pul- 
monary blocking  and  partial  asphy:xia  due  to  the  edema. 
Whatever  this  relation  may  be,  it  is  self-evident  that  the 
usual  case  of  cardiovascular  disease,  which  has  been  inter- 
rupted by  an  acute  pulmonary  edema,  is  accompanied  by 
a  most  striking  pressure  change  which  is  almost  as  strik- 
ingly reduced,  when  the  distressing  symptoms  are  relieved 
(see  Fig.  40). 

Amblard^  states  that  experimental  research  is  amply 
confirmed  by  the  clinical  findings,  and  that  in  high  pressure 

1  Presse  Medicale,  xix,  64. 


BLOOD-PRESSURE   IN    METABOLIC    CONDITIONS  219 

cases  further  elevation  in  blood-pressure,  due  to  cardiac 
insufficiency,  may  precipitate  an  attack  of  acute  pulmonary 
edema;  therefore  careful  attention  to  the  blood-pressure, 
both  systolic  and  diastolic,  to  determine  an  increase  in 
pressure,  or  a  functional  failure  of  the  heart,  should  direct 
attention  to  the  need  of  immediate  reduction  in  the 
maximal  arterial  pressure. 

Cerebral  Hemorrhage. — The  rise  in  pressure  accompany- 
ing the  sudden  development  of  a  cerebral  hemorrhage  of 
traumatic  or  arterionephritic  origin  is  caused  by  the  local 
compression  of  a  part  of  the  brain.  The  effect  of  this 
sudden  and  local  compression  varies  greatly  according  to 
the  location  of  the  compression,  whether  it  be  near  or  far 
from  the  fourth  ventricle. 

Pathology. — According  to  Gushing,  it  is  not  until  the 
intracranial  tension  approximates  the  blood-pressure  that 
profound  changes  in  systolic  tension  occur.  The  effect 
of  this  altered  relation  is  a  stimulation  of  the  vasomotor 
center,  which  is  promptly  followed  by  a  rise  in  blood- 
pressure,  sufficient  to  more  or  less  reestablish  the  normal 
ratio  between  the  intracranial  and  systolic  blood-pressures. 
This  change  is  a  protective  process,  having  for  its  purpose 
the  maintenance  of  cerebral  circulation,  which  is  greatly 
interfered  with  and  which  rapidly  results  in  death  as  the 
two  pressures  approximate,  as  equal  pressure  upon  the  two 
sides  is  incompatible  with  life.  The  ability  of  the  vaso- 
motor center  to  respond  to  this  extraordinary  demand  will 
depend  partly  upon  the  rapidity  with  which  this  response 
is  called  forth  (the  rapidity  of  the  hemorrhage)  and  upon 
the  ability  of  the  heart  to  furnish  the  additional  power 
demanded   by   the  increased   pressure.     Thus   in   severe, 


220 


BLOOD-PRESSURE 


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BLOOD-PRESSURE    IN    METABOLIC    CONDITIONS  221 

sudden  hemorrhages  there  usually  occurs  coma,  slow  pulse, 
altered  respiratory  function  and  a  markedly  elevated 
systolic  pressure,  which  bears  a  direct  relation  to  the 
amount  of  and  rate  of  development  of  the  increased 
intracranial  tension,  whereas  in  cases  where  the  compres- 
sion is  slow,  as  in  brain  tumor,  the  blood-pressure  will  not 
be  materially  affected,  even  though  the  amount  of  brain 
tissue  eventually  subjected  to  destructive  compression  be 

Fig.  40. — Female.  Aged  sixty.  Mitral  incompetence  of  many  years 
standing.  Symptoms  upon  j&rst  examination  chronic  indigestion,  palpitation, 
physical  weakness,  dizziness  and  dyspnea. 

Observations  recorded  in  1912  and  January,  1914,  indicate  the  two 
highest  observations  of  systolic  pressure  made  during  this  period.  At  (A) 
shows  observations  made  one-half  hour  after  relief  from  attack  of  cardiac 
dilatation  with  pulmonary  edema,  unconsciousness,  uncountable  pulse, 
rapid  respiration,  etc.  Relieved  by  hypodermic  of  morphine,  atropin  and 
nitro-glycerin.  The  small  pulse  pressure  when  first  recorded  was  probably 
result  of  the  overuse  of  atropin  which  did  not,  however,  materially  effect 
the  improvement.  Digitalis  and  strychnin  were  then  substituted  with  the 
gratifying  effect  as  shown  between  (A)  and  (B).  During  this  time  the 
patient  was  in  bed. 

At  (B)  there  was  another  moderate  attack  of  dilatation  with  pulmonary 
edema.  Relieved  by  atropin  and  spartein  hypodermatically.  Between  (C) 
and  (D)  the  urine  became  very  scant  and  albuminous,  and  at  (E)  another 
attack  similar  to  the  first  occurred.  This  began  while  the  patient  was  rest- 
ing in  bed  and  from  no  apparent  cause.  Similar  measures  occasioned  a 
sharp  drop  as  indicated,  while  cessation  of  hypodermatic  treatment  caused 
a  rebound  at  (F)  which  was  accompanied  by  an  extremely  high  pulse  pres- 
sure which  did  not  however  appear  to  affect  the  patient's  improvement. 

Between  (F)  and  (G)  sufficient  cardiac  recovery  occurred  to  allow  the 
patient  to  sit  up  for  a  short  time.  Cardiac  irregularity  developed  here 
probably  due  to  the  use  of  digitalis,  which  was  stopped  and  strychnin 
substituted. 

{H)  A  mental  shock  caused  the  sharp  rise  in  systolic  pressure  and  pulse 
pressure,  as  shown,  when  the  patient  suffered  a  slight  relapse. 

(7)  Cardiac  asthma  here  became  a  prominent  symptom  and  persisted 
with  orthopnea  until  the  termination,  together  with  progressively  increasing 
general  edema. 

(J)  Patient  over-exerted  against  advice  and  suffered  symptoms  very  much 
like  those  of  shock  and  in  which  the  pulse  pressure  participated  particularly. 
From  this  point  pulmonary  edema  rapidly  developed  until  the  patient  died 
suddenly. 


222  BLOOD-PRESSURE 

far  greater  than  in  case  of  hemorrhage.  Extremely  high 
pressures  may  be  encountered  in  acute  hemorrhage,  where 
readings  of  400  mm.  and  over  have  been  recorded. 

Diagnosis. — The  value  of  the  blood-pressure  test  in  the 
diagnosis  of  obscure  cases  of  coma  cannot  be  overestimated, 
as  there  is  probably  no  other  single  test  that  can  be  quickly 
applied,  which  will  give  more  valuable  information.  Re- 
peated observations  of  the  systolic  pressure  will  indicate  a 
cessation  of  the  hemorrhage,  as  it  is  unlikely  that  a  sta- 
tionary or  slightly  falling  systolic  pressure  will  occur  in  the 
early  hours  of  a  cerebral  hemorrhage,  unless  the  destructive 
process  has  ceased.  In  regard  to  differential  diagnosis, 
reports  seem  to  show  that  hemorrhage  into  the  anterior 
fossa  affects  blood-pressure  least,  while  when  into  the  pos- 
terior fossa  (near  the  fourth  ventricle)  the  greatest  rise  is 
noted.  From  a  differential  standpoint  the  blood-pressure 
test  may  also  serve  to  distinguish  a  cerebral  hemorrhage  or 
an  apoplectic  coma  from  embolism,  as  in  the  latter  the 
blood-pressure  is  not  high.^ 

Cheyne-Stokes  Respiration. — Pollock^  reports  a  series 
of  blood-pressure  estimations  in  fifteen  cases  of  Cheyne- 
Stokes  respiration  arising  from  various  causes,  which  con- 
firm the  earlier  observations  of  Gushing  that  in  Cheyne- 
Stokes  respiration  with  increased  endocranial  tension,  the 
blood-pressure  is  low  during  the  period  of  apnea  and  high 
during  that  of  hyperpnea,  as  well  as  the  demonstration  by 
Eysner  that  this  fact  is  of  clinical  value  in  the  differentia- 
tion of  Cheyne-Stokes  respiration  with  increased  endo- 
cranial tension  from  other  types.     In  the  cases  with  in- 

*  H.  D.  Jump,  Int.  Clinics,  vol.  i,  21st  Series,  p.  49. 
«  Arch.  Int.  Med.,  vol.  ix,  No.  4,  1912. 


BLOOD-PRESSURE    IN   METABOLIC    CONDITIONS  223 

creased  tension,  the  blood-pressure  began  to  rise  slightly 
before  respiration  commenced  and  began  to  fall  after  the 
summit  of  respiratory  activity  was  reached,  whereas  in  the 
other  cases,  the  pressure  began  to  fall  after  the  beginning 
of  respiration  and  rose  as  respiration  diminished. 

Diabetes  Mellitus. — This  condition,  which  is  usually 
ascribed  to  perverted  pancreatic  function,  manifests  itself 
clinically  through  a  series  of  symptoms  caused  by  a  state 
of  toxemia,  accompanied  in  a  fair  percentage  of  cases  by 
cardiac  and  circulatory  derangement.  The  latter  mani- 
fests itself  usually  in  cardiac  hypertrophy  and  myocardial 
degeneration  combined.  Some  cases  show  arterial  and 
kidney  sclerosis.  This  latter  complication  probably  led 
early  investigators  to  attribute  high  pressures  to  this 
disease.  In  the  light  of  the  combined  statistics  of  more 
recent  investigations  it  appears  that  low  pressure  is  the 
rule,  although  a  continued  high  pressure  accompanies  a 
minority  of  cases. 

A.  R.  Elliott^  studied  a  series  of  cases  of  diabetes  mellitus 
with  the  following  summary  of  results: 

Number  of  cases  observed 25 

Males 13 

Females 12 

Average  age  of  persons 45 

Average  weight  of  patients  (pounds) 156 

Average  systolic  blood-pressure  (mm.  Hg.) 127 

In  this  summary  the  average  systolic  pressure  is  slightly 
misleading,  since,  in  the  thirteen  patients  who  were  under 
fifty  years  of  age,  the  average  pressure  was  107  mm.  Hg., 
while  in  the  twelve  cases  over  fifty  years,  the  average 
was  150.  If  there  is  any  relation  between  the  amount  of 
sugar  and  the  level  of  blood-pressure,  it  would  appear  that  a 

1  Jour.  A.  M.  A.,  xlix,  No.  1,  July  6,  1907. 


224  BLOOD-PRESSURE 

high  percentage  of  glycosuria  favors  a  depression  in  systolic 
level.  This  is  probably  explained  on  the  grounds  that  the 
resultant  emaciation  and  brown  atrophy  or  fatty  change  in 
the  heart  contributes  largely  to  this  condition.  Acidosis 
also  tends  to  a  subnormal  pressure.^ 

As  already  intimated,  the  high  pressure  present  in  some 
cases,  during  the  course  of  diabetes,  can  easily  be  explained 
by  the  presence  of  such  complications  as  chronic  nephritis, 
cardiac  hypertrophy  and  arteriosclerosis. 

Ehrmann,^  considers  blood-pressure  records  of  particular 
value  in  determining  impending  coma,  as  in  many  instances 
he  has  noted  that  there  is  a  marked  decrease  in  the  systolic 
pressure  immediately  preceding  this  phenomenon. 

Mineral  Poisons. — Lead  Poisoning. — The  effect  of  chronic 
lead  intoxication  frequently  results  in  permanent  changes 
in  the  arteries  and  kidneys,  resulting  in  a  secondary  hy- 
pertension. There  is,  however,  a  form  of  hypertension 
occurring  in  lead  poisoning,  as  evidenced  by  the  typical 
colic,  which  is  always  accompanied  by  a  moderate  elevation 
in  blood-pressure,  which  may  remain  elevated  for  several 
days,  succeeding  the  attack  (a  primary  hypertension). 

With  the  knowledge  of  exposure  to  lead,  followed  by  an 
attack  of  typical  pain  with  high  blood-pressure,  we  may  be 
aided  in  difficult  cases  by  the  blood-pressure  test  to  separate 
lead  colic  from  renal  and  hepatic  colic,  in  which  the  blood- 
pressure  is  low. 

Acute  Phosphorus  Poisoning  and  Arsenic  Poisoning — 
These  are  usually  accompanied  by  a  depression  in  systolic 
pressure. 

1  Ehrmann,  Berl.  klin.  Wochen.,  Aug,  4,  1913,  No.  31,  p.  13. 

2  Loc.  cil. 


BLOOD-PRESSURE    IX    MET.\BOLIC    CONDITIONS 


225 


Morphinism. — In  the  average  case  of  chronic  narcotic 
poisoning  the  blood-pressure,  in  the  absence  of  cardio- 
renal  compHcations,  has  been  found  to  below  normal,  al- 
though it  is  stated  that  occasionally  a  case  is  met  in  which 
the  pressure  ranges  between  180  and  200,  which  is  ap- 
parently caused  by  the  attending  constipation,  as  it  is 
usually  relieved  by  a  brisk  purge. 

Momburg  Constriction. — Dr.  Fred  L.  Adair^  has  studied 
twenty-three  cases  in  an  effort  to  determine  the  effect  of 
abdominal  constriction  by  the  Momburg  tube  on  blood- 
pressure,  pulse,  etc.     Cases  showing  abnormalities  of  the 


Adair's  Table  of  Pulse  and  Blood-pressure  (Momburg  Constriction) 


Pulse 

Blood-pressure 

Case 

Before 

During 

Aft 

er 

Before 

During 

After 

Maxi- 

Mini- 

Maxi- 

Mini- 

Maxi- 

Mini- 

Maxi- 

Mini- 

mum 

mum 

mum 

mum 

mum 

mum 

mum 

mum 

1 

95 

97 

97 

88 

88 

116-118 

132 

122 

118 

112 

2 

104 

103 

103 

106 

106 

144 

148 

90 

144 

124 

3 

86 

96 

96 

94 

94 

114-116 

114 

114 

116 

116 

4 

84 

120 

110 

72 

72 

122 

126 

98 

128 

118 

5 

86 

104 

98 

92 

84 

146 

154 

138 

146 

130 

6 

86 

78 

72 

92 

74 

128 

166 

138 

128 

110 

7 

88-102 

122 

116 

98 

98 

144 

148 

111 

140 

140 

8 

98-120 

136 

120 

96 

88 

124 

110 

100 

124 

110 

9 

96 

104 

80 

120 

80 

120 

140 

120 

120 

96 

10 

88 

92 

88 

72 

72 

126 

144 

126 

122 

120 

11 

84 

120 

92 

88 

84 

124 

136 

130 

126 

92 

12 

86-104 

160 

116 

135 

90 

125 

175 

154 

128 

100 

13 

66 

120 

72 

112 

56 

106 

136 

128 

106 

70 

14 

64 

84 

58 

96 

60 

110 

128 

122 

124 

90 

15 

70 

116 

64 

104 

56 

116-118 

184 

158 

122 

110 

16 

84-88 

120 

100 

128 

80 

118 

156 

102 

136 

114 

17 

72 

132 

110 

88 

64 

120 

166 

160 

150 

120 

18 

64 

112 

96 

88 

64 

110 

120 

114 

124 

116 

19 

80 

96 

68 

? 

? 

110 

116 

108 

? 

? 

20 

76 

104 

76 

100 

64 

107 

115 

104 

? 

? 

21 

98 

132 

114 

88 

72 

136 

182 

157 

128 

116 

22 

70 

92 

84 

84 

60 

110-112 

126 

115 

114 

110 

23 

82 

92 

84 

84 

72 

138-140 

166 

156 

132 

124 

^Surg.,  Gyn.  and  Obstet.,  1912,  p.  112. 


15 


226  BLOOD-PRESSURE 

heart,  blood-vessels  or  kidneys  were  excluded  and  all  ob- 
servations were  made  in  the  supine  posture  without  anes- 
thesia. While  of  necessity  the  duration  of  application  was 
short,  the  femoral  pulse  was  always  obliterated.  The 
detail  findings  of  this  series  are  shown  in  the  accompanying 
table,  and  correspond  in  general  with  the  results  of  earlier 
observers,  notably  Wolff.  The  most  dangerous  period 
appears  to  be  when  the  tube  is  removed,  and  this  is  most 
dangerous  in  those  presenting  arterial  change,  cardiac  dis- 
ease, anemia  and  vasomotor  instability. 

Polycythemia. — MoUer^  states  that  in  his  experience  and 
from  a  study  of  literature,  there  is  no  direct  relation 
between  the  level  of  systolic  blood-pressure  and  the  number 
of  red  blood  corpuscles.  In  his  study  of  thirty-five  pa- 
tients, all  with  systolic  pressure  of  180  mm.  or  above,  two 
only  showed  an  abnormal  proportion  of  red  corpuscles. 
On  the  other  hand,  we  know  that  in  conditions  accompanied 
by  anemia,  in  the  absence  of  arterial  and  renal  change,  it 
is  usual  to  find  subnormal  pressures. 

Pleixral  Effusions. — Large  effusions  tend  to  increase 
systolic  pressure  while  their  removal  is  accompanied  by  a 
fall.  Probably  on  account  of  the  proximity  to  the  great 
vessels  and  the  greater  rigidity  of  the  thorax  as  compared 
with  the  abdominal  cavity,  pleural  effusions  occasion  a 
greater  rise  than  do  ascitic.  This  rise  in  pressure  should 
be  taken  into  consideration  when  weighing  the  possibility 
of  the  presence  of  a  coincident  nephritis.  During  the 
removal  of  fluid,  one  may  expect  a  greater  fall  in  recent 
than  in  old  effusions.  The  usual  fall  is  from  15  to  25 
mm.     When  observing  the  blood-pressure  during  the  re- 

1  S.  Moller,  Deutsch.  med.  Wochen,  xxxiv,  Oct.  29,  1908. 


BLOOD-PRESSURE   IN   METABOLIC    CONDITIONS  227 

moval  of  fluid,  a  sudden  fall  accompanied  by  weakness, 
palpitation,  vertigo  or  signs  of  collapse  should  indicate 
the  need  for  a  very  slow  withdrawal  of  fluid  if  not  an 
immediate  cessation. 

This  dangerous  fall  in  pressure  may  be  combated  by  the 
application  of  a  suitable  abdominal  binder  which,  by  in- 
creasing intra-abdominal  pressure,  counteracts  the  sudden 
change  in  pressure  surrounding  the  great  vessels;  trouble 
may  also  be  averted  by  changing  the  posture  of  the  patient 
to  a  reclining  one. 

Prolonged  Epistaxis  Associated  with  Increased  Vascular 
Tension. — Girard  H.  Cocks  ^  and  Harold  Hays^  have  noted 
the  frequent  association  of  prolonged  and  profuse  epistaxis 
with  high  blood-pressure.  Hays  states  that  these  sudden 
and  profuse  hemorrhages  are  usually  associated  with 
one  of  two  classes  of  circulatory  disease. 

1.  Arteriosclerosis  involving  the  arterial  system  and  the 
myocardium. 

2.  Valvular  disease,  or  congenital  deformity  of  the  heart. 
In  the  first  group,  the  epistaxis  seems  to  be  the  direct 

result  of  high  arterial  tension,  and  is  both  a  warning 
sign  of  impending  apoplexy,  and  a  beneficial  act  on  the  part 
of  nature  to  relieve  a  dangerously  high  blood-pressure. 
This  fact  should  lead  to  inquiry  into  the  state  of  the  cir- 
culation, particularly  in  all  persons  of  advancing  years, 
who  show  a  tendency  to  epistaxis,  especially  if  uncontrol- 
lable by  the  usual  means.  Relief  from  both  the  loss  of 
blood  and  the  danger  attending  a  markedly  elevated  pres- 
sure may  best  be  accomplished  by  measures  directed  to- 

1  "The  Laryngoscope,"  January,  1911. 
2iV.  Y.  Med.  Jour.,  Mar.  4,  1911. 


228  BLOOD-PRESSURE 

ward  controlling  the  hypertension.  This  in  Hay's  experi- 
ence is  best  accomplished  in  emergency  by  large  doses  of 
morphia. 

Renal  and  Biliary  Colic. — Abdominal  pain  accompanying 
these  two  conditions  has  no  effect  upon  blood-pressure, 
unless  obscured  by  a  complicating  nephritis.  This  fact 
should  help  to  differentiate  them  from  tabes  and  from  lead 
colic,  both  of  which  give  a  marked  hypertension. 

Shock. — (See  Surgery,  Chapter  XX). 

Thoracic  Aneurysm. — In  thoracic  aneurysm  the  pulsus 
differens  may  be  definitely  determined  by  the  blood- 
pressure  test,  taken  upon  both  arms,  whereas  when  the 
finger  is  employed  one  may  be  greatly  misled  by  the 
findings.  As  an  example  of  this,  in  one  case  of  undoubted 
aneurysm  of  the  last  third  of  the  arch  of  the  aorta  the  left 
radial  seemed  distinctly  smaller  than  the  right,  and  the 
signs  and  radiograph  showed  an  aneurysm  located  ap- 
parently so  as  to  interfere  with  the  flow  of  blood  through 
the  left  subclavian,  but  the  sphygmomanometer  showed  an 
average  of  5  mm.  higher  on  the  left  side  and  an  autopsy 
showed  the  sac  just  below  the  subclavian. 

In  the  differential  diagnosis  between  thoracic  aneurysm 
and  dilatation  of  the  arch  of  the  aorta,  O.  K.  Williamson^ 
says  the  latter  shows  a  greater  increase  in  blood-pressure 
than  the  former,  and  if  the  difference  in  pressure  in  two 
arms  is  30  mm.  or  more,  it  speaks  strongly  for  aneurysm. 
Between  aneurysm  and  mediastinal  tumor  a  difference  be- 
tween the  two  sides  of  20  mm.  or  more  indicates  aneurysm. 
While  these  reports  as  far  as  I  know,  have  not  been  con- 
firmed, and  as  I  have  had  no  experience  in  the  matter, 

1  Laticet,  Nov.  30,  1907. 


BLOOD-PRESSURE   IN    METABOLIC    CONDITIONS 


229 


they  must  be  taken  with  some  question,  but  may  prove 
of  value  in  aiding  the  elucidation  of  difficult  cases. 

Hodgkin's  Disease. — The  etiology  of  this  disease  is  still 
obscure,  the  chief  theories  being  that  of  a  specific  infection 


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Fig,  41. — Hodgkin's  disease.  Male.  Ocean,  pilot.  Aged  seventy-two. 
Cultural  examination  demonstrated  presence  of  the  organism  of  Bunting 
and  Yates.  Responded  to  autogenous  vaccine  for  a  time  as  shown  by  delay 
in  progress  of  symptoms.  Important  characteristics  of  this  chart  are  the 
low  systolic,  the  gradually  reducing  pulse  pressure  together  with  a  rising 
pulse  rate,  this  condition  being  usually  found  in  all  cachectic  states  and 
notably  in  this  disease. 

as  claimed  by  Bunting,  Yates  and  others  and  that  of 
lymphosarcoma.  Whatever  the  cause,  this  disease  is  a 
progressive  and  fatal  one,  having  for  one  of  its  chief  symp- 


230  BLOOD-PRESSURE 

toms  a  marked  reduction  in  systolic  pressure  and  in  pulse 
pressure,  and  because  of  the  comparative  rarity  of  the 
disease  the  chart  ('Fig.  41)  has  been  introduced. 

NEUROLOGIC  DATA 

As  would  naturally  be  supposed  both  functional  and 
organic  affections  of  the  central  nervous  system  produce 
definite  and  easily  demonstrable  effects  upon  the  circulation 
and  blood-pressure. 

Neurasthenia  (See  Hypotension,  Chapter  VIII). — Neur- 
asthenia or  the  fatigue  neurosis  resulting  from  lack  of 
nervous  energy  and  instability  of  the  sympathetic  nervous 
system  is  naturally,  when  uncomplicated,  accompanied  by 
hypotension.  We  may  include  under  this  head  the  psychic 
instability  of  blood-pressure,  so  beautifully  discussed  by 
Schrump^  where  he  shows  that  before  we  may  arrive  at  a 
decision  that  a  low  blood-pressure  is  pathologic,  we  must 
make  sure  that  it  is  not  psychogenic.  He  also  makes  the 
interesting  statement  that  a  rise  in  pressure  of  psychogenic 
origin  affects  chiefly  the  systolic  pressure;  as  the  mind 
does  not  seem  to  have  an  influence  upon  the  diastolic 
pressure,  which  is  unaltered.  Psychic  instability  is  almost 
constantly  present,  in  all  individuals  to  some  degree,  but 
is  much  more  marked  in  the  neuropath.  It  is  sometimes 
difficult  to  determine  by  one  examination  a  normal  from 
a  pathologic  alteration  in  blood-pressure,  and  it  may  be- 
come necessary  to  divert  the  patient's  attention  and  to  re- 
peat the  test  at  a  subsequent  time.  Furthermore,  it  must 
not  be  overlooked  that  the  period  of  absolute  rest  which 

1  Deutsch.  med.  Wochen.,  Dec.  22,  1910. 


BLOOD-PRESSURE    IN    METABOLIC    CONDITIONS 


231 


usually  begins  the  treatment  of  grave  neurasthenia,  is  itself 
a  cause  for  a  lower  blood-pressure.  The  degree  to  which  the 
pressure  falls  in  this  condition  depends  somewhat  upon  the 


Fig.  42. — Female.  Single.  Aged  forty-one.  Typical  neurasthenia  with 
ever-changing  symptoms.  Lacks  initiative  and  is  morose.  Constantly 
worrying  about  her  condition.  Phthisophobe.  Many  kinds  of  treatment 
have  been  only  temporarily  successful.  Elevation  of  pressure  as  shown  in 
the  first  few  observations  probably  result  of  mental  excitement.  This  chart 
shows  well  the  depressed  systolic  pressure,  which  in  spite  of  measures 
directed  toward  restoring  normal  pressure  fails  to  respond,  and  the  extremely 
variable  pulse  pressure,  which  under  usual  conditions  is  smaller  than  normal. 

The  reduction  of  pulse  pressure  tends  to  follow  the  general  physical  condi- 
tion of  the  patient,  yet  in  spite  of  the  small  pulse  pressure  this  patient  at 
no  time  shows  either  renal  or  circulatory  embarrassment. 

gravity  of  the  disease  and  the  temperament  of  the  patient, 
but  is  usually  moderate. 

I  have  been  unable  to  find  any  reference  to  a  hypo- 
tension lower  than  80  mm.  systolic  in  neurasthenia.  See 
Fig.  42. 

The  treatment  of  this  disease  when  successful  may  be 


232  BLOOD-PRESSURE 

indicated  by  a  gradual  return  of  the  pressure  to  normal. 
It  must  be  borne  in  mind  that  complicating  nephritis  may 
so  affect  the  blood-pressure  as  to  render  the  findings  of  no 
value. 

Epilepsy. — According  to  Fisher,^  in  patients  over  forty 
there  is  a  general  tendency  toward  an  elevation  in  pressure 
which  is  not  usually  seen  in  younger  cases.  During  the 
paroxysm  authorities  agree  that  the  systolic  pressure  may 
rise  to  a  great  height  and  remain  high  throughout  the 
attack,  falling  to  an  abnormally  low  level  during  the  sub- 
sequent stage  of  depression.  This  point  may  be  of  value  in 
separating  an  epileptic  from  an  uremic  attack,  as  the  post- 
epileptic fall  does  not  occur  in  cases  of  uremic  origin. 

Tabes  Dorsalis. — Lewellys  F.  Barker  recently  reported 
some  cases  of  this  disease  in  which  the  blood-pressure 
varied  between  190  and  215  mm.  Hg.  Other  authors  have 
had  similar  experience,  noting  the  rise  usually  during  the 
paroxysm  of  abdominal  pain.  Jump-  calls  attention  to 
this  important  differential  point,  that  while  with  abdominal 
pain  in  gastric  crises  of  tabes  the  blood-pressure  is  nearly 
always  markedly  elevated,  it  is  usually  low  or  normal  in 
renal  or  biliary  colic. 

The  common  occurrence  of  arteriosclerosis  in  tabetics 
does  not  appear  to  be  a  cause  for  continued  high  pressure, 
which  in  the  majority  of  cases  is  normal  between  the  crises. 
It  has  been  noted  by  some  observers  that  the  pressure 
rises  some  time  before  the  pains  begin,  which  fact,  if  detected 
by  means  of  the  sphygmomanometer,  may  be  used  thera- 
peutically to  ward  off  the  impending  attack. 

1  Edward  D.  Fisher,  Jour.  A.  M.  E.,  Aug.  3,  1912,  lix.  No.  5,  p.  395. 
^Intemat.  Clinics,  Vol.  i,  Series  21,  p.  49. 


BLOOD-PRESSURE    IN    METABOLIC    CONDITIONS  233 

Mania. — Hawley^  reports  certain  alterations  in  blood- 
pressure  in  maniacs,  which  he  considers  as  typical  of  the 
different  stages  of  this  affection.  Thus  both  the  systolic 
pressure  and  the  pulse  pressure  increase  as  the  restlessness 
of  the  patient  becomes  more  marked,  to  decrease  again  as 
the  patient  recovers  from  the  attack.  Arteriosclerosis  ex- 
isting in  maniacs  accentuates  this  rise,  which  is  gener- 
ally then  maintained  during  the  intervals  of  quiet  and 
depression. 

In  stuporous  cases  the  systolic  pressure  and  pulse  pres- 
sure are  usually  below  normal  and  are  accompanied  by  a 
slow  pulse.  In  depressed  cases  the  systolic  pressure  is  low 
and  the  pulse  pressure  small,  but  not  so  low  as  is  usually 
encountered  in  stuporous  cases. 

Melancholia. — In  melancholia  the  average  systolic  pres- 
sure and  the  pulse  pressure  remain  at  or  near  normal  as 
long  as  there  is  no  muscular  resistance,  or  no  other  factor 
such  as  arteriosclerosis  to  produce  a  rise. 

Paresis.— In  the  majority  of  paretics  the  systolic  pres- 
sure tends  to  a  lower  level  than  in  normal  individuals, 
although  this  is  by  no  means  the  rule,  because  of  the  fre- 
quency of  arteriosclerosis  with  its  cardiac  and  its  renal 
accompaniments.  Walton^  compared  two  groups  of  cases, 
the  first  showing  the  complications  just  referred  to,  while 
in  the  second  group  there  was  no  record  of  arterial,  cardiac 
or  renal  disease. 

Group  I  Group  II 

Age  Systolic  Age  Systolic 

Under  40 125  mm.  Hg.   Under  40 115  mm.  Hg. 

40  to  50 129  mm.  Hg.   40  to  50 mm.  Hg. 

Over  50 147  mm.  Hg.       Over  50 118  mm.  Hg. 

^M.  C.  Hawley,  Arch.  Int.  Med.,  November,  1913. 
2G.  L.  Walton,  Jour.  A.  M.  A.,  Oct.  27,  1906,  xlvii,  17. 


234  BLOOD-PRESSURE 

Schmigergeld^    briefly    summarizes    our    knowledge    of 
blood-pressure  in  general  paresis  as  follows: 

1.  The  blood-pressure  in  this  disease  is  variable. 

2.  In  the  absence  of  complications  the  pressure  in  the 
majority  of  cases  is  subnormal. 

3.  There  appears  to  exist  no  relation  between  the  mood 
of  the  paretic  and  the  state  of  the  blood-pressure. 

»  N.  Y.  Med.  Jour.,  Aug.  28,  1909. 


CHAPTER  XV 
HYPOTENSION 

Definition. — This  term  is  employed  to  designate  altera- 
tions in  arterial  blood-pressure  in  which  the  systolic 
blood-pressure  curve  maintains  an  average  level  below  the 
established  normal  minimum.  The  actual  level  of  this 
pressure  will  be  affected  to  some  degree  by  the  age  and  other 
physiologic  factors,  which  control  the  normal  level  of  pres- 
sure (see  page  42). 

The  Lower  Normal  Limits. — The  limits  are,  of  course, 
largely  arbitrary,  depending  as  they  do  upon  so  many  vari- 
able and  varying  /actors.  To  maintain  their  full  value, 
they  must  be  modified  to  conform  to  our  knowledge  of  the 
many  so-called  physiologic  factors  active  in  each  individual 
case  (see  Chapter  VI). 

Experience  teaches  that  105  mm.  may  be  taken  as  the  low 
limit  of  normal  blood-pressure  in  young  men,  and  95  mm. 
as  the  normal  low  limit  in  young  women.  This  will 
of  necessity  be  modified  slightly  by  the  age,  occupation 
and  muscular  development  of  each  individual.  The  only 
way  to  estimate  the  degree  of  abnormality  in  the  blood- 
pressure  is  to  apply  the  knowledge  obtained  from  experi- 
ence in  examining  a  large  number  of  cases.  Therefore  it 
is  usually  advisable  to  employ  the  blood-pressure  test  as 
a  routine  in  all  cases,  in  order  to  develop  one's  ability  to 
interpret  the  significance  in  each  individual  case. 

Unfortunately,  literature  almost  entirely  lacks  exhaustive 

235 


236  BLOOD-PRESSUKE 

studies  of  low  systolic  pressures,  with  the  exception  of 
certain  definite  conditions,  as  acute  and  chronic  infections, 
shock,  hemorrhage,  Addison's  disease,  etc.,  where  the  ref- 
erences are  many  and  the  data  conclusive. 

Varieties  of  Hypotension. — We  must  admit  the  possibility 
of  a  relative  hypotension,  in  which  the  curve  of  pressure, 
while  above  the  established  normal  is  yet  so  far  below  a 
previous  long-continued  high  pressure,  that  it  presents  the 
physical  phenomena  of  a  pathologic  low  pressure.  This 
point  is  discussed  more  fully  below. 

Hypotension  is  also  encountered  as  a  coincident  phenom- 
enon of  many  pathologic  conditions  in  which  it  is  usually 
the  result  of  the  effect  of  some  substance  or  substances 
affecting  the  cardiac  output,  the  arterial  coats  or  the  vaso- 
motor mechanism.  These  include  infections,  certain  meta- 
bolic diseases,  shock,  hemorrhage,  etc.  Such  conditions 
occasion  a  temporary  hypotension,  which  is  relieved,  as  the 
patient  recovers  or  is  relieved  of  the  metabolic  fault. 
These  conditions  will  be  considered  in  detail  in  appropriate 
sections  and  need  not  now  be  discussed. 

In  order  to  fully  comprehend  the  discussion  which  fol- 
lows, some  form  of  clinical  classification  of  low  blood- 
pressure  must  be  formulated.  The  following  seem  to  be 
the  most  satisfactory  subdivisions: 

(a)  Terminal  hypotension,  (6)  essential  hypotension,  (c) 
relative  hypotension  and  (d)  temporary  or  secondary  hypo- 
tension. 

(a)  Terminal  Hypotension. — The  term  is  used  to  indi- 
cate the  more  or  less  marked  fall  in  systolic  pressure,  usu- 
ally accompanied  by  a  diminishing  pulse  pressure  which 
indicates  the  approaching  end  of  life  (see  Fig.  43). 


HYPOTENSION 


237 


Usually  before  death,  irrespective  of  the  cause,  the  blood- 
pressure  tends  more  or  less  rapidly  toward  zero.  The  rate 
at  which  this  occurs  and  its  relation  to  the  actual  cause  of 
death,  is  determined  by  so  many  factors  about  which  al- 
most nothing  is  known,  that  as  yet  little  may  be  said  with 


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Fig.  43. — Chronic  interstitial  nephritis.  Male.  Aged  fifty-six.  This 
chart  shows  the  rapidity  of  the  rise  in  systolic  pressure  in  a  case  of  chronic 
interstitial  nephritis  and  myocarditis  in  a  patient  of  fifty-six  who  failed  to 
appreciate  the  necessity  of  care  or  treatment  and  was  willing  to,  as  he  said 
"take  his  chances."  Cardiac  dilatation  began  when  the  systolic  pressure 
reached  230  and  rapidly  advanced.  The  patient  died  in  an  attack  of  pul- 
monary edema  with  sj^stolic  pressure  185.  Observations  before  1914 
recorded  on  chart  are  yearly  averages.  1914  observations  show  average 
systolic  pressures  by  months. 

certainty.  According  to  Janeway,  in  protracted  illness 
pressures  as  low  as  60  mm.  (5-cm.  cuff)  may  exist  for  sev- 
eral days  before  death  (note).  In  such  cases  the  hypo- 
tension may  be  of  some  value  as  a  sign  of  impending  dis- 

NoTE. — I  have  seen  a  case  of  acute  bichlorid  poisoning  in  which  a  systolic 
pressure  of  65  was  recorded  several  days  before  death. 


238  BLOOD-PRESSURE 

solution,  but  as  a  rule  the  terminal  fall  in  pressure  is  usually 
a  matter  of  hours  or  even  minutes.  Occasionally  the  fall 
is  too  rapid  to  be  observed  and  an  apparently  normal  sys- 
tolic pressure  may  be  demonstrated  almost  up  to  the 
moment  of  death. 

(6)  Essential  Constitutional  or  True  Hypotension. — 
Definition. — This  type  of  hypotension  may  be  defined  as 
that  form  of  lowered  systolic  blood-pressure  met  in  a  cer- 
tain class  of  individuals  who,  though  not  distinctly  ill,  do 
not  show  evidences  of  robust  health.  These  persons  do 
not  seem  to  have  the  physical  development,  or  circulatory 
power  to  maintain  normal  blood-pressure  values  even  un- 
der the  most  favorable  circumstances.  Systolic  pressures 
of  100  or  lower  are  the  rule  (see  Fig.  42,  page  231). 

Since  the  pioneer  work  of  L.  F.  Bishop  in  this  field,  a 
few  spasmodic  efforts  have  been  made  to  assign  a  definite 
symptomatology  to  this  condition,  and  recently  Goodman* 
has  contributed  a  valuable  paper  upon  this  condition. 

Symptomatology. — These  cases  are  not  actually  ill,  nor 
are  they  ever  well,  but  complain  of  all  sorts  of  symptoms 
which  can  be  traced  directly  to  low  pressure  as  the  only 
assignable  cause. 

Such  individuals  are  unable  to  withstand  any  prolonged 
or  severe  physical  exertion  without  fatigue. 

They  have  not  only  a  habitually  low  pressure  but  they 
also  respond  very  poorly  and  uncertainly  to  measures 
directed  toward  improving  the  circulation  or  to  those 
stimuli  which  in  the  normal  person  result  in  a  rise  in 
pressure. 

The  pulse  pressure  is  usually  smaller  than  normal,  indi- 

1  E.  H.  Goodman,  Am.  Jour.  Med.  Sci.,  April,  1914. 


HYPOTENSION  239 

eating  a  defective  cardiac  output,  while  there  is  no  relation 
between  blood-pressure  and  pulse  rate. 

These  cases  are  usually  associated  with  enteroptosis  and 
may  have  a  tendency  to  attacks  of  temporary  dizziness, 
upon  sudden  change  of  posture;  many  are  undoubtedly  of 
intestinal  toxemic  origin.  Constipation  tends  to  keep  the 
pressure  down,  as  does  also  a  marked  indicanuria,  which  is 
so  frequently  encountered  in  these  cases.  Headaches  are 
frequent,  and  are  often  relieved  by  measures  directed 
toward  increasing  the  pressure.  These  cases  wake  up 
tired,  then  improve  during  the  early  hours  of  activity,  only 
to  become  exhausted  long  before  the  end  of  the  day. 

Many  are  thin  and  poorly  nourished,  and  suffer  con- 
tinually from  chilly  hands  and  feet,  which  are  often  moist 
and  may  be  actually  wet.  The  dependent  hands  are 
bluish  and  when  one  is  elevated  to  above  the  head  for  a 
short  time  it  becomes  abnormally  pale. 

Those  patients  lack  initiative,  and  every  movement  seems 
to  be  an  effort;  even  when  shaking  hands,  it  is  done  in  a 
half-hearted  manner,  and  life  is  generally  viewed  through 
dark  glasses.  They  are  decidedly  of  the  depressive  neuras- 
thenic type.  Mental  tire  is  often  extreme  in  spite  of  the 
evidently  active  mind.  Some  of  these  cases  undoubtedly 
belong  to  the  class  of  congenitally  small  hearts  and  arteries. 

(c)  Relative  Hypotension. — This  term  would  seem  to  be 
a  necessary  one  and  should  be  applied  to  those  cases  whose 
actual  pressure,  while  still  above  the  estimated  normal,  has 
fallen  from  a  former  pathologic  high  level  to  such  a  degree 
that  symptoms  due  to  the  fall  have  developed.  A  fairly 
common  example  of  this  is  the  frequent  occurrence  of  edema 


240 


BLOOD-PRESSURE 


or  other  signs  of  circulatory  failure  following  injudicious 
attempts  to  reduce  a  high  pressure. 

The  same  condition  obtains  in  a  failing  cardiovascular 
system,  when  the  pressure  has  been  for  a  long  time  high. 
(See  chart,  Fig.  44.)  Here  also  we  may  have  most  serious 
and  distressing  symptoms,  pointing  to  circulatory  failure, 
and  yet  the  pressure  may  be  found  still  above  the  estimated 
normal  level. 


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Fig.  44. — Hypotension  of  lost  compensation  (relative  hypotension). 
Arteries  markedly  sclerosed,  heart  showed  myocardial  degeneration,  pulse 
always  rapid.     Cerebral  symptoms  marked,  treatment  had  very  little  effect. 

{d)  Secondary  or  Temporary  Hypotensions. — All  other 
cases  presenting  an  abnormally  lowered  systolic  pressure 
should  at  present  be  placed  under  this  head.  Etiologically 
these  cases  will  be  found  singly  or  combined  to  be  due  to 
cardiac,  vasomotor,  actual  muscular  or  of  blood  volume  or 
composition  changes. 


HYPOTENSION  241 

G.  M.  Piersol^  has  conveniently  grouped  the  several 
causes  as  follows: 

1.  Hypotension  due  to  vasodilatation,  shock  and  col- 
lapse from  whatever  cause. 

2.  Acute  infections  and  toxemias. 

3.  Hypotension  due  to  cardiac  weakness,  as  in  chronic 
myocardial  degeneration,  acute  dilatation,  arteriosclerosis 
and  chronic  nephritis. 

4.  Orthostatic  albuminuria  and  amyloid  disease,  not 
associated  with  true  nephritis. 

5.  Advanced  cachexias,  occurring  in  the  course  of  car- 
cinoma, diabetes  and  nephritis. 

6.  Hypoplasia  of  the  chromaffin  system  as  in  Addison's 
disease. 

7.  Hypotension  due  to  diminished  blood  volume  as  in 
cholera,  persistent  diarrhea,  dysentery,  cholera  infantum. 
Graves'  disease  and  hemorrhage. 

8.  Certain  nervous  affections,  of  which  paresis  and  epi- 
leptic coma  are  examples,  also  true  neurasthenia. 

9.  Drug  poisons,  as  tobacco.  This  ordinarily  raises  blood- 
pressure,  with  the  apparent  anomaly  that  heavy  smokers 
frequently  have  subnormal  pressures.  For  the  effect  of 
drugs  on  blood-pressure,  see  Chapter  XXIII,  page  409. 

10.  There  are  many  examples  met  with  of  the  so-called 
gouty  or  rheumatic  manifestations  of  lumbago,  sciatica,  or 
neuritis  which  show  a  blood-pressure  somewhat  below  nor- 
mal. Many  of  these  cases  have  a  subnormal  acidity  of 
the  urine,  and  are  liable  almost  constantly  to  a  copious 
deposit  of  phosphates  which  leads  to,  or  is  accompanied  by, 
a  state  of  nervous  depression. 

1  Penn.  Med.  Jour.,  May,  1914,  xvii,  No.  8. 

16 


242  BLOOD-PRESSURE 

Extreme  Low  Pressure. — The  lowest  blood-pressure  in 
an  adult  compatible  with  life  has  been  reported  by  Neu 
to  be  from  40  to  45  mm.,  and  this  only  occurred  with  sub- 
normal temperature  accompanied  by  unconsciousness.  He 
has  observed  and  recorded  recovery  after  a  temporary  fall 
in  pressure  as  low  as  50  mm. 

Pressures  of  80  to  95  are  not  uncommon,  and  may  per- 
sist for  long  periods,  to  be  followed  finally  by  a  recovery 
of  normal  values. 

Effects  and  Danger  of  Hypotension. — The  direct  effect 
of  a  falling  blood-pressure  is  the  accumulation  of  an  ab- 
normal amount  of  blood  in  the  veins,  and  a  slowing  of  the 
current  in  the  arteries.  This  will  affect  the  capillary  circu- 
lation and  interfere  with  the  nutritive  and  secretory  proc- 
esses which  depend  upon  it.  The  most  serious  effect  is  on 
the  heart,  as  it  has  been  shown  that  complete  loss  of  vaso- 
motor tone  soon  leads  to  death,  because  of  the  gradual 
accumulation  of  nearly  all  the  blood  in  the  body  on  the 
venous  side,  so  that  the  heart  has  no  blood  upon  which  to 
act. 


CHAPTER  XVI 
HYPERTENSION;  HYPERPIESIS 

The  term  hypertension,  is  generally  applied  to  any  con- 
dition in  which  the  blood-pressure  is  maintained  at  a  level 
above  normal,  irrespective  of  the  degree  or  duration  of  the 
elevation.  Such  use  of  the  term  admits  of  confusion  and 
doubt  in  the  mind  of  the  reader,  because  of  the  diversity 
of  conditions  included  in  so  comprehensive  a  term.  The 
fact  that  careful  clinicians  continue  to  report  cases  with 
hypernormal  blood-pressure,  in  the  absence  of  either  car- 
diac or  nephritic  degenerative  changes,  and  since  we  are 
able  to  obtain  a  permanent  and  lasting  return  to  normal 
blood-pressure  values  in  certain  cases  by  appropriate 
treatment  and  hygiene,  it  would  seem  to  justify  an  effort 
to  limit  this  term  and  to  admit  the  presence  of  such  a 
clinical  entity,  having  as  a  prominent  symptom,  a  transi- 
tory elevation  of  systolic  pressure;  for  if  we  fail  to  recog- 
nize this  clinical  condition,  there  will  remain  an  unfilled 
gap  in  our  clinical  conception  of  cardiovascular  and  renal 
pathology. 

That  we  may  accept  this  condition  as  a  pathologic  and 
clinical  entity,  is  shown  by  the  fact  that  its  existence  is 
recognized  by  many  modern  authorities,  among  them 
Janeway,^  Butler,^  R.  A.  Torrey,^  T.  C.  Janeway,^  and 
H".  W.  Cook.5 

1  Am.  Jour.  Med.  Sci.,  1906,  cxxxi. 

2  The  Practitioner,  1909,  Ixxii. 

3  Penna.  Med.  Jour.,  April,  1914. 

4  Jour.  A.  M.  A.,  Dec.  14,  1912,  lix,  p.  2106, 
6  Jour.  A.  M.  A.,  Jan.  28,  1915,  Ixiv,  No.  4, 

243 


244 


BLOOD-PRESSURE 


Definition   of   Hyperpiesis   or   True   Hypertension. — It 
would  seem  best,  at  least  for  clinical  purposes,  to  limit  the 


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Fig.  45. — Hypertonia  vasorum;  upper  line,  section  of  normal  artery 
middle,  section  of  contracted  artery;  lower,  section  of  artery  restored  to  it 
natural  partial  contraction.     (L.  F.  Bishop,  in  Medical  Record.) 


term  hyperpiesis  or  true  hypertension,  to  a  well-recognized 
symptom-complex  in  which  the  rise  in  systolic  pressure 
is  moderate  and  persistent,   but  not  permanent,  and   to 


HYPERTENSION ;    HYPERPIESIS 


245 


designate  all  other  high  pressures,  which  are  either  de- 
pendent upon,  or  accompanied  by  distinct  and  clinicaUy 
recognizable  arterial,  kidney  or  heart  changes,  as  high 
blood-pressure.  Thus  we  limit  the  term  hypertension  to 
an  elevation  of  blood-pressure  dependent  largely,  if  not 
solely,  upon  a  muscular  change  in  the  arterial  walls  and 

BLOOD  PRESSURE  CHART 


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Fig.  46. — Illustrates  pure  hypertension  and  the  efifect  that  may  be  expected 
to  follow  measures  directed  toward  relief  of  underlying  toxemia. 

capillaries^  whereby  they  are  temporarily  narrowed  and 
contracted.  This  corresponds  to  the  ''Hypertonia  Vas- 
orum"  of  Bishop^  given  in  his  classification  of  arterial  dis- 
orders, and  (see  Fig.  45)  which  may  be  overcome  by  ap- 

1  Wm.  Russell,  "Arterial  Hypertension,  Sclerosis  and  Blood-pressiire," 
PhUadelphia,  1908. 

2  L.  F.  Bishop,  Med.  Rec,  Dec.  4,  1909. 


246  BLOOD-PRESSURE 

propriate  treatment  (see  Fig.  46) ;  as  contrasted  with  true 
high  pressure,  where,  in  addition  to  other  conditions,  there 
is  a  permanent  pathologic  change  in  the  arterial  coats, 
either  in  part  or  as  a  whole,  and  which  is  never  entirely 
overcome  by  treatment. 

By  adhering  to  this  distinction  we  are  immediately  en- 
abled to  appreciate  the  inherent  pathology  of  this  condi- 
tion, and  also  to  understand  the  different  results  obtained 
by  methods  directed  either  toward  its  relief,  or  the  relief 
of  the  resultant  symptoms. 

Etiology. — Regarding  the  cause  or  causes  of  hypertension 
in  its  restricted  sense,  these  may  be  summed  up  in  the 
word  "intoxication,"  although  much  yet  remains  to  be 
explained  concerning  the  precise  nature  of  the  processes 
leading  to  its  production.  The  causes  are  essentially  the 
same  as  those  producing  arteriosclerosis,  but  differ  in  that 
they  have  acted  over  a  shorter  period  of  time  and  are 
probably  less  active  in  character.  This  belief  is  borne  out 
by  the  clinical  fact  that,  if  permitted  to  continue,  the  con- 
dition gradually  progresses  until  it  imperceptibly  merges 
into  and  becomes  one  of  true  arteriosclerosis  and  cardio- 
renal  disease. 

That  the  adrenals  and  other  members  of  the  chromaffin 
system  play  an  important  role  is  shown  in  various  ways. 
Recently  Sergent  and  Cottintot^  have  shown  that  irradia- 
tion of  the  adrenals  in  eleven  cases  of  hypertension,  in 
which  all  known  causes  of  this  condition  had  been  elimi- 
nated, caused  a  reduction  in  systolic  pressure  of  from  40  to 
50  mm.  Hg.  Obesity,  which  is  considered  by  some  ob- 
servers to  be  another  phase  of  disturbed  internal  secretion, 

1  Jour.  A.  M.  A.,  Mar.  28,  1914,  Ixii,  13,  p.  1032. 


HYPERTENSION ;   HYPERPIESIS 


247 


Fig.  47.— Hypertonus.  Female.  Married.  Aged  thirty-three.  Has 
always  enjoyed  good  health.  Very  energetic.  Has  a  tendency  to  over- 
weight and  laces  very  tightly.  The  rise  in  pressure  (A)  is  wholly  unex- 
plained. There  being  no  corroborative  findings,  which  would  suggest 
nephritis.  This  is  probably  a  case  of  pure  hypertonus  which,  if  unarrested, 
will  gradually  merge  into  one  of  permanent  cardio-renal  disease.  The 
remission  in  pressure  following  (A)  was  accomplished  by  hygienic  means, 
while  the  morning-evening  observations  (5)  were  made  before  the  patient 
arose  m  the  mornmg  and  in  the  evening  after  an  ordinary  day's  occupation. 
Tight  lacing  and  nervous  temperment  are  undoubtedly  factors  in  this 
case.  (C)  Phthalein  test  at  this  date  resulted  as  follows:  1st  hour  40  per 
cent.,  2d  hour  20  per  cent.,  3d  hour  10  per  cent.  Total  70  per  cent. 
Urinalysis  usually  showed  albumen  varying  from  a  trace  to  a  moderate 
amount,  a  normal  specific  gravity,  and  occasional  cylindroid  and  hyaline 
casts. 


248  BLOOD-PRESSURE 

has  been  suggested  by  C.  Fessinger^  as  another  possible 
cause  of  this  condition,  because  in  thirty  out  of  160  persons 
of  excessive  weight  showing  hypertension,  he  was  able  to 
eliEoinate  all  other  probable  causes  excepting  overweight. 

Schlayer^  advances  the  plausible  theory,  and  presents  an 
array  of  evidence  to  sustain  it  that  hypertension  when  per- 
sistent is  due  to  a  condition  in  which  the  arterial  system 
has  become  sensitized  by  some  means,  rendering  it  hyper- 
susceptible  to  epinephrin  or  other  similar  substances  and 
to  other  toxins  which  may  be  circulating  in  the  blood.  The 
source  of  this  sensitization  may  be  in  the  kidney,  even 
though  the  kidney  changes  when  present  are  usually  a 
parallel  phenomenon.  Clinical  observations  seem  to  sus- 
tain this  assumption,  explaining  at  the  same  time  why 
simple  rest  and  increased  elimination  have  such  beneficial 
influence  on  the  condition. 

Provocative  Causes. — These  are  the  same  as  those  which 
enter  largely  into  the  production  of  arteriosclerosis  and  its 
complications,  differing  only  in  that  they  are  more  mild  in 
their  impression,  and  act  intermittently  or  have  a  shorter 
duration.  These  are  considered  more  fully  under  the  head 
of  Arteriosclerosis,  to  which  subject  they  properly  belong 
(see  page  261).  Suffice  it  to  say  here  that  it  is  generally 
recognized,  from  both  clinical  and  pathologic  standpoints 
that  the  etiologic  factors  are  the  same,  and  that  the  con- 
ditions met,  hypertension  only  or  high  blood-pressure,  will 
depend  largely  upon  the  susceptibility  of  the  individual 
(see  Fig.  47),  the  activity  of  the  toxic  agents  and  the  dura- 
tion of  their  influence. 

1  Bull,  de  I'Acad.  de  Med.,  Apr.  16,  1912,  Ixxvi,  16. 

2  Munch.  Med.  Wochen.,  Jan.  14,  1913,  Ix,  No.  2. 


hypertension;  hyperpiesis  249 

Symptomatology. — Hypertension  is  a  subtle  condition 
often  lurking  where  least  suspected.  There  may  be  no 
change  in  the  palpable  arteries  except  a  barely  distinguish- 
able narrowing  and  stiffening  when  rolled  under  the  finger, 
a  hardly  noticeable  change  in  the  aortic  second  sound, 
possibly  a  faint  systolic  whiff  at  the  aortic  cartilage,  while 
the  urine  remains  practically  normal.  The  systolic  blood- 
pressure  will  be  found  to  be  from  140  to  180  mm.,  depend- 
ing upon  the  degree  of  arterial  contraction. 

By  many,  a  progressive  change  in  the  arteries  and  a 
gradually  rising  blood-pressure  are  looked  upon  as  normal 
conditions  in  late  middle  life  or  in  early  old  age. 

Hypertension  is,  I  believe,  always  a  sign  of  the  beginning 
of  a  pathologic  change,  which  according  to  Huchard,  Rus- 
sell and  others  is  the  danger  signal,  a  warning  that  some 
alteration  must  be  made  in  the  daily  life,  or  the  primarily 
curable  condition  will  progress  and  merge  into  cardio- 
vascular-renal disease  (see  Fig.  48). 

A  permanent  increase  in  blood-pressure  in  the  young 
adult,  or  in  early  middle  life,  in  the  absence  of  discoverable 
organic  change  in  the  heart,  blood-vessels  or  kidneys,  is 
always  a  sign  of  chronic  toxemia;  a  poisoning  arising  from 
some  error  in  metabolism  or  dejficiency  of  elimination  either 
intestinal  or  urinary  or  both.  Such  a  rise  in  blood-pressure 
is  rarely  discoverable,  except  by  the  routine  estimation  of 
blood-pressure  of  those  coming  under  the  physician's  ob- 
servation either  as  patients  or  for  examination  for  life 
insurance.  In  the  early  stages  symptoms  referable  to  the 
condition  either  must  be  rare,  or  if  mentioned  are  attributed 
to  overwork,  mental  worry,  neurasthenia,  etc.  On  the 
other  hand,  by  careful  questioning  suggestive  symptoms 


250 


BLOOD-PRESSURE 


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Fig.  48. — Toxic  Migraine.  Male.  Aged  forty-three.  From  a  member  of  a 
famUy  in  which  typical  migraine  headaches  are  common,  having  occurred  in 
the  patient's  father,  mother,  aunt  and  sister.  In  this  patient  these  attacks 
come  on  with  great  regularity,  at  seven-  or  eight-day  intervals.  \Mien  first 
seen  these  headaches  were  causing  great  annoyance  by  interfering  with  his 
daily  activities.  Refractive  errors  have  been  corrected.  The  Wassermann 
reaction  is  negative.  The  patient  is  of  sedentary  habits  and  is  a  large  eater. 
His  work  is  purely  mental.  The  patient  is  constipated  and  the  urine,  upon 
frequent  examinations  showed  evidence  of  intestinal  toxemia.  Therapeutic 
efforts  were  directed  solely  toward  eUmination  of  toxemia  and  resulted  in 
considerable  relief  until  the  patient  at  (A)  returned  from  a  ten  days'  business 
trip.  During  this  time  he  had  several  headaches  and  a  number  of  dizzy 
spells.  Dietetic  measures  were  again  instituted  with  the  following  result, 
namely,  a  moderate  decrease  in  systolic  pressure  with  a  great  fall  in  pulse 
pressure  incident  to  an  approximation  of  systolic  and  diastolic  pressures. 
The  rise  at  (B)  seemed  to  be  incident  to  a  return  of  constipation  which 
was  relieved  by  exercises. 


hypertension;  hyperpiesis  251 

may  be  elicited,  such  as  fleeting  dizziness,  throbbing  tem- 
ples, tinnitus  aurium,  disturbed  sleep,  cold  hands  and  feet, 
gastric  distress  and  flatulency,  constipation,  lack  of  interest 
and  of  power  of  concentration,  diminished  desire  to  be  up 
and  doing,  distaste  for  physical  exertion  and  weakened 
tolerance  for  substances  which  affect  the  brain,  such  as 
alcohol  and  tobacco. 

The  blood-pressure  does  not  need  to  be  greatly  increased 
in  order  to  injure  the  heart  and  cause  permanent  change 
in  the  blood-vessels  and  in  the  kidneys.  The  additional 
amount  of  work  required  of  the  heart  to  overcome  the  re- 
sistance of  a  few  millimeters  of  mercury  mounts  up  sur- 
prisingly (see  page  275). 

Concerning  the  actual  systolic  pressure  level  encountered 
in  hypertension  as  contrasted  with  that  found  in  cases 
where  arteriosclerosis  and  degenerative  changes  have  de- 
veloped, most  authorities  agree  upon  160  to  170  mm.  Hg. 
as  the  dividing  line,  although  this  is  by  no  means  arbitrary, 
since  it  is  well  known  that  well-developed  cases  of  arterio- 
sclerosis and  nephritis  may  exist  with  systolic  pressures 
averaging  lower  than  170,  and  that  apoplexy  has  occurred 
in  patients  who  have  never  shown  a  systolic  pressure  of 
over  170. 

The  diastolic  pressure  will  be  found  elevated,  but  to  a 
less  degree  than  the  systolic  pressure,  this  giving  a  moder- 
ately increased  pulse  pressure,  but  the  difference  is  rarely 
as  great  in  proportion  as  shown  by  the  pulse  pressure  usu- 
ally met  in  arteriosclerosis  and  nephritis.  A  typical  case 
might  present  the  following:  systolic  pressure  160,  diastolic 
pressure  100,  pulse  pressure  60.  It  would  be  an  error  to 
base  a  diagnosis  upon  this  alone  as  only  repeated  study 


252  BLOOD-PRESSURE 

and  the  careful  weighing  of  all  evidence,  permits  the  arrival 
at  a  safe  and  correct  opinion. 

Diagnosis. — This  requires  fine  judgment,  is  always 
diflScult  and  becomes  additionally  so  as  the  boundary  line 
between  hypertension  and  arteriosclerosis  is  approached. 

It  will  be  a  great  aid  to  diagnosis  to  keep  the  fact  con- 
stantly before  the  mind  that  hypertension  is  a  cardio- 
vascular (largely  vascular)  function  of  a  temporary  nature, 
which  we  now  recognize  and  correct,  while  arteriosclerosis 
is  a  permanent  pathologic  change  of  the  tissues  of  the  ar- 
terial walls  for  which  we  know  no  remedy. 

The  eliciting  of  a  group  of  otherwise  unexplainable 
symptoms  as  enumerated  above,  in  the  absence  of  demon- 
strable (after  careful  and  repeated  search)  lesions  of  the 
heart  and  kidneys,  and  with  only  a  moderately  elevated 
systolic  pressure  (below  170)  and  a  slightly  increased  pulse 
pressure,  in  persons  susceptible  to  auto-intoxication,  as 
those  of  sedentary  habits  or  accustomed  to  overeating, 
especially  when  blood-pressure  reducing  measures  rapidly 
reestablish  normal  blood-pressure  values,  should  afford  the 
clinician  a  reliable  diagnosis.  A  note  of  warning  should  be 
sounded  here,  which  is  that  one  should  not  be  too  ready  to 
make  a  positive  diagnosis  of  pure  hypertension,  as  it  is 
safer  to  err  on  the  side  of  the  more  grave  condition  and  so 
proceed  in  the  treatment.  This  will  avoid  a  too  sanguine 
view  of  a  possibly  serious  case  which  at  first  being  con- 
sidered trivial,  later  develops  into  one  of  true  arterial  or 
renal  disease. 

Syphilis  is  well  recognized  as  a  cause  of  hypertension;  it 
acts  in  the  same  manner  as  other  circulating  toxins  and 


hypertension;  hyperpiesis  253 

therefore  may  be  looked  for  as  one  factor  in  the  production 
of  hypertension  (see  also  Chapter  XIII). 

Concerning  the  relationship  between  true  hypertension 
and  permanent  renal  and  arterial  changes,  we  are  coming 
more  and  more  to  the  view  that  high  blood-pressure  is 
primary  and  the  involvement  of  the  kidneys  and  arteries 
only  incidental.^ 

This  seems  only  natural  when  we  realize  the  great  sur- 
face area  of  arterial  walls  which  are  exposed  to  the  action 
of  irritating  substances  in  the  circulating  blood,  as  com- 
pared with  which  the  kidneys  actually  only  receive  a  small 
portion  of  these  toxic  irritants. 

1  A.  W.  Hewlett,  Jour.  A.  M.  A.,  May  25,  1912,  Iviii,  No.  21. 
V.  Bie,  Ugeskriftm  f.  Sarger.,  Mar.  4,  Ixxxvii,  No.  9. 
Cottentot  and  Sergent,  Jour.  A.  M.  A.,  Mar.  28,  1914,  Ixii,  No.  13,  p. 
1032. 


CHAPTER  XVII 
ARTERIOSCLEROSIS 

In  any  consideration  of  this  subject  we  should  primarily 
insist  upon  an  absolute  distinction  between  hypertension 
and  arteriosclerosis.  Arterial  hypertension  is  a  cardio- 
vascular phenomenon  having  perversions  and  abnormali- 
ties which  the  diagnostician  can  now  recognize  and  in 
many  instances  successfully  arrest  and  correct  (see  Chap- 
ter XVI,  page  243).  Arteriosclerosis  is  a  permanent  patho- 
logic change  of  tissue  for  which  there  is  no  remedy.  The 
source  of  danger  in  arteriosclerosis  is  not  primarily  in  the 
thickened  artery  but  in  the  amount  of  permanent  blood- 
pressure  elevation  accompanying  it.  The  thickened  artery 
itself  is  a  physiologic  development  of  a  protective  nature 
and  represents  a  factor  of  safety  rather  than  a  source  of 
danger. 

Latterly  our  conceptions  concerning  the  origin  and  devel- 
opment of  arteriosclerosis  have  undergone  great  changes, 
largely  due  to  the  fact  that  during  the  past  few  years 
much  experimental  work  has  been  carried  on  and  many 
clinical  investigations  made,  which  in  great  measure  prove 
the  causative  relation  of  a  large  number  of  exciting  agents, 
the  effect  of  which,  either  directly  or  indirectly,  on  the 
vessel  walls  is  the  provocative  cause  of  arteriosclerosis. 
In  another  direction,  studies  have  demonstrated  the  rela- 
tion of  this  condition  to  abnormally  and  persistently  high 

254 


ARTERIOSCLEROSIS  255 

blood-pressure  and  to  cardiac  and  renal  diseases  (see  Chap- 
ter XIX  and  Chapter  XVIII). 

While  admitting  that  in  the  present  incompleteness  of 
our  knowledge  on  this  subject,  final  and  conclusive  proof  of 
the  relation  of  the  various  agents,  supposed  to  be  funda- 
mentally responsible  for  the  development  of  vascular  and 
renal  sclerosis  is  still  lacking,  because  they  are  extremely 
difficult  and  in  many  cases  impossible  of  demonstration, 
nevertheless  it  would  seem  highly  desirable,  from  the  clin- 
ical standpoint,  to  accept  the  data  at  hand  (both  clinical 
and  pathologic),  and  for  the  present  at  least  to  separate 
and  to  consider  individually,  hypertension,  arteriosclerosis, 
cardiomuscular  and  renal  diseases,  as  causes  of  persistent 
high  blood-pressure  and,  by  a  careful  analysis,  attempt  to 
establish  their  predominant  etiologic  relation  to  changes 
in  the  arterial  wall,  the  heart  muscle  and  the  kidneys,  as 
the  case  may  be,  in  each  case  of  high  pressure  studied. 

In  the  following  pages  the  purely  scientific  investigator 
should  not  be  too  critical  of  the  conclusions  drawn,  but 
should  allow  the  author  some  latitude  in  dealing  with  this 
still  open  subject,  as,  throughout,  the  chief  effort  has  been 
to  reduce  a  very  large  and  complicated  subject  to  a  prac- 
tical working  basis,  one  that  may  be  applied  to  conditions 
met  in  daily  practice.  After  all,  this  is  the  chief  concern 
of  the  practitioner. 

PHARMACODYNAMIC   STUDIES   OF  THE  CAUSE   OF 
ARTERIOSCLEROSIS 

Much  of  the  experimental  work  in  the  study  of  arterio- 
sclerosis has  involved  the  artificial  production  of  arterio- 
sclerosis chiefly  by  the  introduction  of  a  number  of  chem- 


256  BLOOD-PRESSURE 

ical  and  biologic  substances  into  the  circulation  of  animals. 
Many  of  these  substances  are  those  which  have  theoretic- 
ally been  suspected  to  be  the  direct  exciting  causes  of 
arteriosclerosis  or  which  have  been  demonstrated  to  be 
present  in  excess  in  such  cases. 

Among  the  more  important  substances  held  to  be  re- 
sponsible for  this  condition  are:  the  salts  of  cholin;  excess 
of  adrenalin  in  the  circulating  blood;  toxins,  as  those  of 
syphilis;  acute  infections;  typhoid  fever;  etc.  Poisonous 
substances  resulting  from  abnormal  proteid  metabolism, 
as  indol,  amino-acids;  excess  of  normal  proteid  material  in 
the  blood,  and  excess  of  cholesterin  in  the  blood ^  (favored 
by  excessive  exercise,  narcotics,  adrenalin,  etc.). 

Among  the  many  obstacles  to  the  full  understanding  and 
satisfactory  demonstration  of  the  true  relation  of  the  excit- 
ing causes  are  the  diversity  of  substances  at  present  held 
to  be  responsible  for  the  condition  and  which  frequently 
may  be  coincidentally  important.  It  is  also  a  fact  that  all 
cases  of  arteriosclerosis  do  not  present  high  blood-pressm'e, 
neither  do  all  cases  of  high  blood-pressure  show  evidences  of 
arteriosclerosis;  it  is  equally  true  that  a  large  group  of 
apparently  dissimilar  causes  may  result  in  arteriosclerosis: 
yet,  nevertheless,  the  bulk  of  dependable  evidence 
now  tends  to  show  that  high  blood-pressure  usually  pre- 
cedes the  permanent  change  in  the  arterial  wall  (see 
page  244). 

S.  E.  DeSajous^  attempts  to  overcome  this  apparent  dis- 
crepancy by  showing  a  logical  biochemical  relation  between 
the  majority  of  these  agents.     Thus  he  says:  "While  the 

*  Wacker  and  Houck,  Munch.  Med.  Wochen.,  Sept.  14,  1913. 
'Jour.  A.  M.  A.,  Aug.  3,  1912,  lix,  5. 


ARTERIOSCLEROSIS  257 

adrenal  secretion  acts  on  the  muscular  fibers  of  the  heart, 
and  of  the  arteries  in  general,  it  has  been  found  that  the 
brunt  of  this  action  is  borne  by  the  arterioles.  When  such 
action  is  abnormal,  we  may  have  the  production  of  arterio- 
sclerosis. All  the  main  causes  usually  assigned  to  arterio- 
sclerosis may  be  summed  up  by  the  word  'intoxication.' 
All  but  one  of  the  morbid  conditions  known  to  provoke 
arteriosclerosis  (alcohol  has  not  been  studied)  have  also 
been  shown  to  cause  over-activity  of  the  adrenals,  and  the 
evidence  of  this  effect  is  further  substantiated  by  the  fact 
that  Coplin,  in  an  examination  of  the  adrenals  of  twenty- 
two  cases  of  arteriosclerosis,  found  that  seventeen  were 
markedly  altered,  the  glands  in  the  other  cases  being  the 
seat  of  either  tuberculosis  or  a  secondary  neoplasm." 

Thayer  and  Brush ^  have  studied  at  varying  periods  of 
months  and  years  after  their  infection,  189  cases  who  passed 
through  typhoid  fever.  Their  results  showed  that  be- 
tween the  ages  of  ten  and  fifty,  48.3  per  cent,  of  old  ty- 
phoids had  palpable  radials  as  compared  with  17.5  among 
ordinary  healthy  individuals  in  whom  serious  infections 
and  alcoholic  habits  had  been  excluded. 

The  average  systolic  pressure  was  materially  higher  for 
every  decade  in  old  typhoids  as  compared  with  normal. 

The  average  size  of  the  heart  was  larger  among  old 
typhoids  than  in  normals  when  arranged  in  groups  accord- 
ing to  age. 

They  were  also  greatly  impressed  with  the  frequency  of 
signs  of  endarteritis  in  the  aorta  and  coronaries  of  patients 
dying  with  typhoid;  this  condition  being  found  in  fifty- 

1  W.  S.  Thayer  and  W.  E.  Brush,  Jr.,  Jour.  A.  M.  A.,  Sept.  10,  1914, 
xliii,  11. 
17 


258  BLOOD-PRESSURE 

two  out  of  ninety-five  necropsies,  while  there  was  fresh 
arteriosclerosis  in  twenty-one  instances. 

They  were  unable  to  form  any  conclusive  opinion  in  re- 
gard to  the  relation  of  venereal  diseases  because  of  the  ab- 
surdly small  proportion  of  cases  who  admit  such  infection. 

In  further  substantiation  of  the  infectious  toxic  theory, 
H.  Huchard^  reports  an  analysis  of  the  etiology  of  1835 
cases  of  arteriosclerosis  in  the  order  of  their  frequency  as 
follows:  (1)  rheumatism,  18  per  cent.;  (2)  gout,  17  per 
cent.;  (3)  syphilis,  11  per  cent.;  (4)  tobacco,  9  per  cent.; 
(5)  other  acute  toxemias,  3  per  cent.;  (6)  diabetes,  2  per 
cent.;  (7)  alcohol,  malaria,  nervous  causes,  1  per  cent,  or 
less;  (8)  unassignable  causes,  30  per  cent. 

S.  Dratschinski,^  in  a  communication  issuing  from  Met- 
chnikoff's  laboratory,  confirms  his  previous  announcement 
as  to  the  toxicity  of  indol  and  its  relation  to  the  production 
of  arteriosclerosis. 

On  the  other  hand  the  early  work  of  Adler  and  HenseP 
obtained  possible  results  of  only  twelve  out  of  ninety  rab- 
bits in  which  they  endeavored  to  produce  arteriosclerosis 
by  the  injection  of  irritating  drugs  normally  present  in  the 
human  economy. 

Stuckey  has  endeavored  to  show  that  the  feeding  of 
abnormal  amounts  of  albuminous  foods  may  be  productive 
of  arteriosclerosis.  In  experimenting  with  rabbits  he  suc- 
ceeded in  producing  a  hypertrophy  of  the  intima,  which 
was  chronic  and  persistent  in  nature,  and  which  appeared 
to  be  identical  with  the  change  seen  in  arteriosclerosis  in 
man. 

^  Bulletin  de  I'Acad.  de  Medecine,  July  7,  1908,  Ixxii,  27, 
^  Annal.  de  I'Instit.  Pasteur,  June,  1912,  xxvi,  6. 
'Jour.  A.  M.  A.,  June  1,  1907,  xlviii,  22,  p.  1896. 


ARTERIOSCLEROSIS  259 

Martin  Bishoff^  failed  to  produce  arteriosclerotic  changes 
by  the  administration  of  graduated  amounts  of  alcohol  to 
rabbits. 

C.  Hirsch  and  O.  Thorspoken^  administered  adrenalin 
intravenously  to  rabbits  and  obtained  advanced  changes 
in  the  intima  so  intense  as  to  remind  one  of  well-marked 
arteriosclerosis  in  the  human. 

Popielski's  belief  in  the  physiologic  behavior  of  the  salts 
of  cholin  in  raising  blood-pressure  and  in  the  production 
of  arteriosclerosis  has  not  been  substantiated,  since  Mendall, 
Underhill  and  Renshaw^  have  noted  that  cholin  salts  pro- 
duce a  characteristic  transitory  fall  of  pressure;  neither  do 
they  believe  that  the  ''contamination  "  theory  is  probable,  as 
properly  prepared  and  preserved  cholin  salts  are  not  readily 
decomposed. 

As  the  common  effect  of  circulating  toxins  is  a  hyperemia 
and  stimulation  of  the  adrenals,  it  is  fair  to  suppose  that 
this  relation,  as  suggested  by  Sajous,^  is  to  some  degree 
at  least  an  ever  present  one. 

In  demonstration  of  the  toxic  theory  Y.  Manouelian^ 
injected  rabbits  and  monkeys  with  filtrates  of  emulsions 
of  staphlyococci  and  produced  arteriosclerotic  changes  in 
86  per  cent,  of  the  rabbits  and  in  five  out  of  six  monkeys. 

I.  Adler^  has  raised  the  question  as  to  whether  the 
effect  on  the  vessel  walls  is  due  to  the  actual  substance 
suspected  or  to  some  intermediate  substance.  When  in- 
jecting dogs  both  intravenously  and  subcutaneously  with 

^Zeit.  f.  exp.  Path,  im  Therap.,  No.  11,  1912. 

2  Deutsch.  arch.  f.  klin.  Med.,  1912,  No.  107. 

3  Jour.  Pharmacol,  and  Exper,  Therap.,  July,  1912,  iii,  6. 
^  Loc.  cit. 

^  Annal.  de  V Instil.  Pasteur,  xxvii,  No.  1. 
'Jour.  A.  M.  A.,  June  6,  1914,  Ixii,  23. 


260  BLOOD-PRESSURE 

epinephrin,  nicotin,  lead,  diphtheria  toxin  and  pure  cul- 
tures of  different  species  of  bacteria,  he  obtained  no  effect, 
while  in  a  second  series  of  experiments  with  these  same 
substances,  when  administered  orally,  he  obtained  positive 
effects. 

L.  F.  Bishop^  states  that  heart  disease  and  hardening  of 
the  arteries  are  nine  times  out  of  ten  due  to  disturbance  in 
the  chemistry  of  the  body  (of  the  adrenals,  the  thyroid, 
toxemias,  etc.),  particularly  in  relation  to  the  intestines  and 
the  liver.  According  to  this  authority  the  most  important 
cause  of  arteriosclerosis  is  amino-acid  poisoning,  by  acids 
to  which  the  individual  tissues  are  sensitive.  Intestinal 
putrefaction  has  a  very  important  bearing.  He  believes 
that  idiosyncrasy  accounts  for  the  susceptibility  in  certain 
individuals  as  compared  with  others. 

The  amino-acids,  which  are  responsible  for  these  condi- 
tions, are,  in  all  probability,  derived  from  the  breaking 
down  in  the  intestinal  tract  of  nitrogenous  foods  derived 
from  milk,  eggs,  fish,  meat  and  soups.  And  here  he  ex- 
pressed the  view  already  published  by  Rudolph^  who  quotes 
Huchard  by  saying,  that  the  second  most  important  factor 
in  the  production  of  arteriosclerosis  is  the  continued  ex- 
cretion of  toxins  by  the  kidney,  these  toxins  coming  from 
abnormal  proteid  metabolism  in  the  digestive  tract  and 
also  in  the  liver. 

INCIDENCE  OF  ARTERIOSCLEROSIS 

While  this  disease  usually  is  looked  upon  as  one  of  the 
second  half  of  life  and  is  encountered  usually  during  de- 

^Jour.  A.  M.  A.,  Mar.  15,  1913,  Ix,  No.  11. 
2  Brit.  Med.  Jour.,  Nov.  26,  1910. 


ARTERIOSCLEROSIS  261 

clining  years,  it  should  not  be  forgotten  that  well-marked 
cases  are  often  met  before  the  age  of  thirty  and  an  occa- 
sional apoplexy  has  been  reported  in  the  early  twenties. 

The  development  of  arterial  disease  and  its  complica- 
tions are  attracting  more  and  more  attention,  because 
reports  show  the  condition  to  be  on  the  increase.  Insur- 
ance statistics,  particularly,  point  to  the  fact  that  both  the 
age  and  incidence  (development  of  symptoms)  and  the 
percentage  of  cases  encountered  are  advancing,  the  disease 
being  met  in  earlier  life  and  more  frequently  than  even  a 
decade  ago. 

This  unfortunate  prevalence  seems  attributable  to  the 
increased  tension  and  the  greater  artificiality  of  the  life 
led  by  the  average  business  and  professional  man  to-day. 
Statistics  show  that  men  are  more  frequently  victims  of 
arteriosclerosis  than  women. 

ETIOLOGY  OF  ARTERIOSCLEROSIS 

Having  discussed  the  "exciting  agents"  of  arteriosclero- 
sis, we  now  come  to  a  consideration  of  what  may  be  con- 
veniently called  the  "productive  or  provocative  causes." 
By  this  is  meant  those  conditions  which  clinically  are 
looked  upon  as  entering  actively  into  the  etiology  of  the 
disease  and  which  are  found  pathologically  to  be  favorable 
to  the  development  of  this  disease  by  contributing  to  the 
production  or  liberation  of  the  "exciting  agents"  which  are 
themselves  directly  responsible  for  the  arterial  changes 
found  in  arteriosclerosis  (see  page  246)  and  which  are 
characteristic  of  the  disease. 

In  reviewing  the  relation  of  these  "provocative  agents" 


262 


BLOOD-PRESSURE 


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Fig.  49. — Female.  Aged  sixty-seven.  Diagnosis:  Chronic  myocarditis 
and  arteriosclerosis.  Previous  history  one  of  hard  work.  Family  history  one 
of  cardiovascular  disease.  First  symptom  dated  four  years  previously  and 
included  loss  of  weight,  dimness  of  vision,  constant  dyspnea  with  occasional 
orthopnea,  palpitation,  dizziness,  headaches,  edema  of  the  ankles,  physical 
weakness  and  abdominal  pain.  Examination  shows  moderate  edema  of  legs 
up  to  knee,  no  ascites,  a  large  and  tender  liver,  transverse  enlargement  of  the 
heart,  chiefly  to  the  left,  apex  not  palpable,  a  slight  systolic  murmur  at  the 
apex,  very  irregular  cardiac  rhythm,  including  variations  in  strength  of  the 
impulses  with  intermissions  and  extra-systoles.  Difference  in  26  beats 
between  radial  count  and  apex  count.  Arteries  slightly  thickened,  slight 
general  cyanosis,  urine  shows  large  amount  of  albumen,  normal  specific 
gravity  with  hyaline  casts  not  alwaj^s  present. 

Morphine,  rest  and  elimination  resulted  in  reduction  in  pressure  chiefly 
systolic  from  (A)  to  (JB)  accompanied  by  some  relief  from  all  symptoms. 
The  dyspnea  has  been  held  in  control  by  the  intermittent  alternating  use  of 
digitalis  and  strychnin. 

The  response  to  this  treatment  is  gradually  becoming  lessened,  while  the 
tendency  to  an  elevated  sj'stoUc  pressure  becomes  more  persistent. 

The  case  is  one  very  difficult  to  manage  and  is  working  her  own  distruc- 
tion  by  failure  to  adhere  to  restrictions  particularly  in  regard  to  physical 
exertion. 

Note.  Since  the  preparation  of  this  chart  the  patient  has  shown  a  systolic 
pressure  persistently  in  the  neighborhood  of  200  with  almost  continuous 
orthopnea,  nocturnal  cardiac  asthma  and  several  attacks  very  suggestive 
of  angina  which  are  relieved  by  the  use  of  heroin. 


ARTERIOSCLEROSIS  263 

two  difficulties  are  met  in  attempting  to  place  formally  the 
responsibility.  First  the  indisputable  fact  that  arterio- 
sclerosis does  not  invariably  follow  in  the  wake  of  these 
causes,  even  when  they  appear  to  be  very  active  and  when 
their  influence  has  persisted  for  a  great  length  of  time. 
Second,  the  almost  universal  existence  of  multiple  "provo- 
cative causes"  in  the  history  of  any  given  case,  and  the 
nearly  utter  impossibility  of  indicating  definitely  the  single 
cause,  if  indeed  any  single  cause  be  found  to  exist  (see 
Fig.  49). 

Accepting  the  existence  of  at  times  unsurmountable  ob- 
stacles, in  the  way  of  isolating  the  cause  of  the  disease  in 
any  particular  case,  we  are  now  in  a  position  to  review  the 
statistics  available  and  to  understand  the  apparent  dis- 
crepancies found.  Finally,  to  form  our  own  conclusions, 
which  can  be  adopted  to  our  individual  needs  and  employed 
as  diagnostic  leads  in  the  course  of  practice. 

One  of  the  earliest  statistical  reports  is  that  of  Huchard^ 
who  reported  the  causative  factor  in  2680  cases  of  arterio- 
sclerosis found  in  15,000  patients  seen  in  the  course  of 
private  practice.  In  their  relative  frequency  these  were 
as  follows:  gout,  uricemia,  food,  syphilis,  tobacco  poison- 
ing, worry,  mental  over-exertion  and  alcohol. 

Herz's^  more  extensive  study  covered  the  tabulation  of 
reports  of  the  most  frequent  cause  furnished  him  by  822 
different  observers.  This  composite  report  gives  as  fol- 
lows the  relative  frequency  of  causes  as  met  by  each  con- 
tributor: 

^  Med.  klin.  Berlin,  v,  No.  35. 

2  Wien.  klin.  Wochen.,  xxiv,  No.  44. 


264 


BLOOD-PRESSURE 

Emotional  and  nervous 150 

Physical  exertion 146 

Age 138 

Alcohol 133 

Tobacco 88 

Syphilis 77 

Heredity 72 

Metabolic  disturbances 19 

Cofifee  and  tea 13 

Infections,  etc 7 


Thayer^  tabulates  his  study  of  3894  cases  in  their  order 
of  frequency  as  follows:  heavy  work  (62.2  per  cent.),  alco- 
hol, rheumatism,  diphtheria,  scarlet  fever,  malaria  and 
pneumonia. 

Brooks^  studied  400  cases  and  heads  the  list  with  occu- 
pational lead  poisoning,  severe  manual  labor,  alcohol, 
nephritis,  syphilis  and  tuberculosis. 

Thayer  and  Brush  admit  that  the  majority  of  cases  give 
a  history  of  multiple  factors  which  they  do  not  attempt  to 
separate  but  which  they  divide  into  four  groups  : 

First. — Manual  labor,  57.6  per  cent. 

Second. — Alcohol,  46.8  per  cent. 

Third. — Acute  infections. 

(o)  Rheumatism,  34.6  per  cent. 
(6)  Typhoid  fever,  26.3  per  cent. 

Fourth. — Those  having  acute  infections  alone  (variety 
not  stated),  24.3  per  cent. 

Rodger  I.  Lee^  reports  the  following  causes  present  in 
the  percentages  given  below  which  in  the  majority  of 
instances  were  multiple. 

1  N.  Y.  Med.  Jour.,  June  18,  1904. 

2  A.  M.  A.  Jour.  Med.  Sci.,  May,  1906. 
'^Jour.  A.  M.  A.,  Oct.  7,  1911,  Ivii,  No.  15. 


ARTERIOSCLEROSIS 


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266  BLOOD-PRESSUKE 

Per  cent. 

Kidney  lesions 71 

Arteriosclerosis 69 

Arteriosclerosis  and  kidney  combined 52 

Cerebral  lesions 15 

Cardiac  lesions 24 

High  pressure  and  arteriosclerosis  (kidney  normal) 28 

Pure  hypertension 13 

Janeway  has  been  led  to  believe  that,  in  cases  of  gener- 
alized arteriosclerosis  which  show  high  blood-pressure  (Fig. 
50)  this  pressure  is  largely  due  to  a  kidney  condition  as 
most  cases  of  generalized  arteriosclerosis  without  kidney 
involvement  are  unassociated  with  high  pressure  (about 
50  per  cent.). 

This  observer  was  fortunate  in  being  able  to  follow  many 
of  his  cases  to  necropsy,  thereby  being  able  to  compare  the 
clinical  and  pathologic  diagnosis.  His  study  brought  out 
the  marked  imperfections  in  our  present  methods  of  diag- 
nosis, by  demonstrating  that  a  large  percentage  of  clinical 
diagnoses  were  either  incorrect  or  incomplete  when  checked 
by  the  pathologic  report. 

SUMMARY 

Considering  all  the  evidence,  a  few  important  facts  stand 
out  clearly,  namely,  (a)  that  well-developed  generalized 
arteriosclerosis  affects  blood-pressure  chiefly  when  the 
arteries  of  the  general  arterial  tree  are  involved,  without 
which  blood-pressure  may  not  be  altered  even  by  marked 
local  arteriosclerosis,  (b)  That  thickening  and  degenera- 
tive changes  in  the  intima  result  wholly  or  in  part  through 
the  irritating  effect  of  abnormal  metabolites  or  other  irri- 
tating substances  circulating  in  the  blood,  and  that  these 
substances  may  operate  through  the  agency  of  the  nervous 


ARTERIOSCLEROSIS  267 

system  through  stimulation  and  congestion  of  the  adrenals  or 
directly  by  local  irritation  upon  the  vessel  lining,  (c)  The 
origin  of  these  substances  is  diverse,  probably  in  the  major- 
ity of  cases  of  gastro-intestinal  or  liver  origin,  although 
toxic  substances  of  an  infectious  nature  are  also  of  great 
importance,  {d)  The  majority  of  cases  of  arteriosclerosis 
are  preceded  by  a  period  of  slightly  elevated  blood-pressure 
due  to  a  narrowing  or  hypertension  of  the  arterial  walls; 
and  this  change  is  at  first  transitory,  but  by  being  con- 
stantly repeated  the  arterial  system  is  subjected  to  an 
intermittent  trauma,  which  is  productive  of  a  permanent 
alteration  of  a  degenerative  character  in  the  fibrous  coats 
of  the  arteries,  (e)  This  change  is  largely  a  protective 
effort  on  the  part  of  nature  to  strengthen  the  artery  in 
order  to  withstand  the  added  strain.  In  order  to  overcome 
the  resistance  offered  by  the  hypertension  (/)  the  heart 
hypertrophies,  while  disturbance  in  renal  circulation  inter- 
feres with  proper  elimination,  thus  throwing  additional 
irritating  substances  into  the  circulation,  thereby  estab- 
lishing a  vicious  circle,  which  gradually  increases  as  the 
pressure  mounts  higher  and  higher,  unless  relief  comes  from 
a  break  at  some  point. 

PATHOLOGY 

The  term  arteriosclerosis  is  too  loosely  employed  by  the 
average  physician.  This  has  led  to  great  confusion  in  the 
reporting  of  cases  and  in  the  compilation  of  statistics.  It 
is  often  impossible  to  learn  precisely  what  condition  an 
author  is  discussing,  so  that  the  benefits  of  careful  research 
are  often  lost  to  the  reader.  The  two  conditions  usually 
confused   are,   atheroma  and  diffuse  generalized  arterio- 


268  BLOOD-PRESSURE 

sclerosis,  and  less  often  the  condition  of  pure  hypertension, 
as  found  before  any  permanent  change  has  occurred  in  the 
vessel  wall  (see  page  244). 

The  pathologist  has  more  than  once  pointed  out  clearly 
these  different  conditions  and  has  correlated  them  with 
the  physical  signs.  Among  them  Russell  has  made  most 
careful  studies  of  the  condition  of  the  vessels,  and  their 
relation  to  chronic  disease  of  the  heart,  kidneys,  cerebral 
system,  and  to  blood-pressure.  According  to  Russell,^ 
atheroma  is  a  local  or  patchy  affection  of  the  arteries 
characterized  by  a  local  thickening  and  degeneration  of  the 
intima.  This  soon  undergoes  a  form  of  fatty  degeneration 
which  is  termed,  atheroma.  Later  these  patches  become 
the  seat  of  a  calcareous  deposit  while  in  the  larger  arteries 
atheromatous  cysts  and  ulcers  may  be  formed  with  local 
sacculations.  These  changes  may  be  so  extensive,  espe- 
cially in  the  aortic  arch  that  a  local  bulging  occurs  to  which 
the  name  aneurysmal  bulging  has  been  applied. 

Atheromatous  changes  are  quite  common  in  the  cerebral 
and  coronary  arteries  but  comparatively  rare  in  the  radials. 
When  present  in  the  radials,  they  give  rise  to  local  thicken- 
ings, which  give  an  irregular  nodular  feel  to  the  vessel. 
They  are  never  symmetric.  Russell  believes  that  the 
character  of  these  changes  is  very  suggestive  of  a  low- 
grade  infection,  and  assigns  a  primary  micro-organismal 
implantation  as  their  origin. 

Arteriosclerosis,  on  the  other  hand,  may  be  roughly 
defined  as  a  thickening  of  the  arterial  wall  with  a  diminu- 
tion in  the  size  of  its  lumen.     The  changes  which  have  led 

*  Wm.  Russell,  "Arterial  Hypertension,  Sclerosis  and  Blood-pressure," 
J.  B.  Lippincott  Co.,  1910. 


ARTERIOSCLEROSIS  269 

to  this  when  examined  in  detail  are  seen  to  consist  of  (1) 
a  marked  thickening  of  the  intima,  due  to  hypertrophy  of 
the  muscle  fibers;  (2)  a  thickening  of  the  intima  without 
atheromatous  degeneration;  (3)  and  in  some  cases  a  fibrous 
thickening  of  the  adventitia.  The  muscular  coat  may 
show  some  degeneration  but  the  prevailing  notion  that  in 
such  thickened  vessels  the  muscle  coat  is  replaced  by 
fibrous  tissue  (fibrous  degeneration)  is  erroneous  (Russell) 
(Thayer  and  Brush). 

These  changes  are  not  confined  to  limited  areas  of  the  ves- 
sel wall  as  in  atheroma,  but  affect  uniformly  a  large  portion 
of  the  vascular  system  and  are  usually  distributed  throughout 
the  body,  for  instance,  in  the  coronary  and  renal  arteries. 

Cases  are  encountered  where  both  processes  are  met  in 
combination.  Usually  these  occur  late  in  life,  the  ath- 
eromatous changes  generally  being  confined  to  the  large 
vessels  and  aorta. 

The  cHnical  study  of  blood-pressure  and  its  relation  to 
visceral  involvement  would  seem  to  bear  witness  to  the 
accuracy  of  P^ussell's  deductions  and  conclusions,  for  it  will 
be  recognized  that  were  this  change  one  of  pure  fibrous 
degeneration  with  destruction  of  the  muscular  tissue  in  the 
vessel  walls,  then  measures  directed  toward  relieving  hy- 
pertension (contraction  of  the  muscular  wall)  would  be  use- 
less. As  proof  of  this  and  of  the  value  of  such  measures,  we 
have  only  to  review  the  evidence  found  in  every-day  prac- 
tice, where  such  measures  effect  a  reduction  in  a  large 
majority  of  cases. 

CLINICAL  MANIFESTATIONS 

CUnically  the  elevation  of  pressure  in  arteriosclerosis 
affords  a  method  of  distinguishing  between  this  disease 


270  BLOOD-PRESSURE 

and  atheroma  with  which  it  is  so  often  confused.  Ather- 
oma is  really  a  senile  affection,  coming  on  in  persons  be- 
tween sixty  and  eighty  years  and  which  involves  the  blood- 
vessels only.  Arteriosclerosis  on  the  other  hand  may  at- 
tack persons  between  thirty  and  sixty  years  of  age  and  is 
largely  a  visceral  complaint  involving  as  it  progresses,  the 
heart,  kidneys  and  nervous  system.  Although  Oppen- 
heim^  has  reported  two  cases  of  undoubted  arteriosclerosis  in 
boys  of  nine  and  ten  years  of  age.  The  first  died  of  spon- 
taneous rupture  of  the  aorta,  probably  of  syphilitic  origin, 
while  the  second  case  was  undoubtedly  due  to  autotoxemia. 

With  the  study  of  atheroma  we  are  but  little  concerned 
as  this  condition  must  be  looked  upon  as  a  more  or  less 
natural  process  due  to  the  changes  caused  by  advancing 
years,  and  not  particularly  related  to  those  factors  which 
are  recognized  as  producing  arteriosclerosis. 

Gull  and  Sutton's  original  conception  of  this  disease  as 
an  '^Arteriocapillary  Fibrosis"  is  incomplete.  From  the 
viewpoint  of  the  pathologist,  the  clinician  and  the  thera- 
peutist, we  must  recognize  the  multiplicity  of  the  causes 
involved  in  arteriosclerosis  and  admit  that  the  condition 
is  usually  a  joint  involvement  of  the  heart,  the  blood- 
vessels and  the  kidneys,  in  which  the  arterial  changes  may 
be  determined  to  be  the  predominant  factor  in  a  certain 
per  cent,  of  cases. 

From  a  purely  clinical  standpoint  it  would  seem  con- 
venient, even  if  not  scientifically  correct,  to  divide  the 
evolution  of  arteriosclerosis  according  to  the  four  divisions 
first  suggested  by  Huchard.^     Thus: 

1  Virch.  Arch.,  vol.  clviii,  No.  2. 

2  Jour.  A.  M.  A.,  Vol.  liii,  No.  14,  p.  1129. 


ARTERIOSCLEROSIS  271 

1.  Arterial  hypertension  (presclerosis). 

2.  The  cardioarterial  stage. 

3.  The  reno-arterial  stage. 

4.  The  final  stage  of  cardiac  failure. 

Such  a  classification  will  be  found  very  valuable  to  the 
practising  physician,  because  the  mere  placing  of  a  case  in 
one  of  these  divisions  (and  it  is  usually  possible  to  do  this) 
will  at  once  greatly  aid  in  giving  a  prognosis,  and  also  sug- 
gest the  character  of  the  treatment  indicated. 

Clinically,  arteriosclerosis  may  begin  in  the  kidneys,  in 
the  heart,  in  the  extremities  (in  laborers  or  farmers),  in 
the  brain,  or  in  the  mesentery;  but  there  cannot  be  gen- 
eralized arteriosclerosis  without  both  cardiac  and  renal 
involvement. 

SYMPTOMATOLOGY 

In  the  cases  presenting  pipe-stem  and  tortuous  arteries 
with  ringing  aortic  second-sound  and  a  long  list  of  suggest- 
ive cardiorenal  symptoms,  so  often  seen  in  elderly  indi- 
viduals with  interstitial  nephritis,  the  diagnosis  is  made  for 
us,  and  the  treatment  is  of  little  avail.  It  is  to  the  early 
and  unsuspected  cases,  those  presenting  few  if  any  symptoms 
or  signs  of  disease,  in  which  there  is  present  little  or  no 
palpable  change  in  the  peripheral  arteries,  doubtful  change 
In  the  valve  sounds,  perhaps  a  little  roughening  of  the  sec- 
ond sound,  with  a  normal  or  practically  normal  urine,  that 
our  attention  should  be  directed.  These  cases  may  and 
usually  do,  after  diligent  search,  show  obscure  gastro-intes- 
tinal  symptoms  which  so  frequently  fail  to  obtain  proper 
consideration  from  the  clinician.  Such  cases  usually  have 
a  systolic  range  of  from  160  to  250  mm.  Hg.  (see  Fig.  53), 
and  an  increased  pulse  pressure  of  which  the  increase  in 


272  BLOOD-PRESSURE 

pulse  pressure  is  of  greatest  significance.  For  this  will  be 
found  in  arteriosclerosis  even  when  accompanied  by  a  nor- 
mal systolic  pressure. 

In  persons  about  to  enter  or  already  in  middle  life,  these 
blood-pressure  changes,  in  the  absence  of  demonstrable 
nephritis,  may  be  the  only  physical  sign  pointing  directly 
toward  the  diagnosis. 

With  regard  to  an  exact  symptomatology  of  early  gen- 
eralized arteriosclerosis,  the  clinical  signs  and  subjective 
symptoms  may  simulate  almost  any  known  disease  and 
present  almost  any  clinical  signs,  from  a  fleeting  dizziness 
to  gangrene  of  the  extremities.  Some  of  the  symptoms  are 
not  infrequently  attributed  to  neurasthenia.  There  are 
vague,  unpleasant  feelings  or  fullness  in  the  head,  slight 
momentary  dizziness,  cold  hands  and  cold  feet,  sleep  unre- 
freshing  and  disturbed  by  dreams,  gastric  distress  and 
flatulence  coming  on  one  or  two  hours  after  meals,  constipa- 
tion and  loss  of  power  of  concentration  and  interest  in 
business  affairs.  The  general  vitality  and  power  of  resist- 
ance of  the  body  is  less  than  formerly  and  tolerance  for 
substances  which  affect  the  brain,  as  alcohol  and  tobacco 
is  often  diminished.  The  patients  tire  easily.  As  the 
process  advances  the  gastric  symptoms  increase  in  severity 
and  exertion  after  meals  may  bring  on  attacks  of  gastric 
and  heart  pain,  which  are  relieved  only  by  resting.  Such 
individuals  become  incapacitated  for  work.  They  are 
nervous,  lose  weight  and  move  slowly.  Evidence  of  in- 
volvement of  all  the  organs  in  the  arteriosclerotic  process 
appears,  notably  in  the  brain,  the  heart,  the  eyes  and  the 
kidneys.  Extreme  cases  give  all  the  classical  symptoms 
and  signs  which  go  to  make  up  the  syndrome  of  cardio- 


ARTERIOSCLEROSIS 


273 


vascular-renal  disease.     By  this  time  the  diagnosis  is  as 
easy  as  the  treatment  is  difficult. 

Cases  of  arteriosclerosis  which  have  sustained  a  high 

BLOOD  PRESSURE  CHART 

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Treatment  was  largely  directed  toward  a  chronic  intestinal  toxemia.  The 
marked  fall  in  pressure  resulting  from  a  relaxation  of  hypertonus,  while  the 
further  failure  to  bring  the  pressure  below  165  indicates  the  failure  of  such 
measures  to  affect  a  permanent  change  in  the  vessel  walls. 

pressure  over  considerable  time  show  periods  of  great  de- 
pression with  severe  headaches,  nausea  and  sudden  vertigo. 
This  is  due  to  the  irritation  and  diminished  nutrition  of  the 
cerebral  centers  from  the  high  pressure  and  the  narrowed 


274 


BLOOD-PRESSURE 


arteries.  Eventually  these  symptoms  become  more  or  less 
constant,  memory  fails  and  insomnia  ensues,  while  life  be- 
comes a  burden.^ 

BLOOD  PRESSURE  CHART 


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Fig.  52. — Symptoms  chiefly  cerebral,  September  20,  patient  slightly  de- 
lirious, some  muscular  weakness  on  left  side  of  body.  Chart  shows  effect  of 
active  treatment  continued  until  September  23.  Remainder  of  chart  shows 
lowered  pressure  maintained  by  physical  measures  after  patient  resumed 
his  activity. 

Often  it  is  not  until  these  cases  suffer  a  cerebral  hemor- 

*  Cerebral  type  of  Bing,  R.  Bing,  Correspond,  bl.  d.  Schwr.  Aerz.,  August, 
1912,  xlii,  22. 


ARTERIOSCLEROSIS  275 

rhage  or  show  signs  of  cardiac  weakness,  that  they  are  even 
suspected  of  having  anything  more  than  a  nervous  condi- 
tion. Routine  observations  of  blood-pressure  and  a  prac- 
tical knowledge  of  the  early  signs  of  this  disease  are  essen- 
tial if  a  diagnosis  is  to  be  made  in  time  to  obtain  benefit 
from  preventive  measures.  The  routine  estimation  of 
blood-pressure  and  the  preparation  of  a  daily  chart  is  of 
great  value  in  the  study  of  suspicious  cases  such  as  simple 
chronic  bronchitis  with  emphysema,  which  are  often  ex- 
plained and  their  etiologic  factors  supplied  by  demonstrat- 
ing the  presence  of  continued  high  pressure.  Indeed  the 
blood-pressure  need  not  be  very  much  elevated  to  injure 
the  heart  and  other  organs,  for  an  increase  of  a  few  milli- 
meters, if  long  continued,  entails  an  enormous  increase  in 
the  daily  work  of  the  heart. 

DIAGNOSIS 

Of  primary  importance  in  the  diagnosis  of  any  chronic 
condition  is  the  taking  of  a  thorough,  carefully  arranged 
and  comprehensive  history.  It  should  cover  all  points  in 
the  patient's  personal,  social  and  previous  medical  history. 
Take  nothing  for  granted  and  leave  no  important  point 
uninvestigated.  Properly  taken  and  carefully  summarized 
the  history  alone  will  often  suggest  the  diagnosis  and  will 
indicate  the  direction  for  special  study  which  may  serve 
to  establish  a  definite  diagnosis. 

The  preceding  paragraphs  have,  I  think,  sufficiently 
emphasized  the  important  symptoms  which  should  be 
sought  so  that  repetition  is  unnecessary.  A  thorough 
physical  examination  is  desirable,  followed  by  such  subse- 
quent special  examinations  as  are  indicated  by  already 


276  BLOOD-PRESSURE 

acquired  information.  These  will  usually  include  the  blood- 
pressui'e  and  the  functional  capacity  of  the  circulation  by 
the  means  of  the  sphygmomanometer,  the  condition  of  the 
blood,  of  the  eye-grounds  and  of  the  urine. 

Examination  of  the  Arteries. — For  diagnostic  purposes 
we  may  assume  that  the  arterial  wall  may  usually  be 
demonstrated,  by  palpation,  to  be  thickened  after  the  age 
of  forty  years  (Daland^).  This  seems  very  practical  from 
a  diagnostic  standpoint  when  we  consider  that  a  demon- 
stration of  the  state  of  the  vessels  is  purely  a  relative  com- 
parison and  that  to  ignore  this  premise  would  lead  into  error 
resulting  in  a  diagnosis  of  arteriosclerosis  in  patients  hav- 
ing vessels  with  no  more  than  a  normal  degree  of  thickening. 

Observation  is,  therefore,  first  directed  toward  a  study 
of  all  accessible  vessels  by  means  of  inspection  and  palpa- 
tion, not  forgetting  those  of  the  retina  by  means  of  the 
ophthalmoscope.  The  study  of  the  radial  arteries  gives 
most  valuable  information,  but  it  must  not  be  forgotten 
that  the  fibrotic  process  may  be  inconspicuous  in  the  per- 
ipheral arteries  while  well  advanced  in  the  internal  arteries, 
more  especially  the  splanchnic  and  cerebrals;  and  that 
occasionally  fibrosis  may  be  advanced  in  the  peripheral 
vessels  but  little  or  no  change  in  the  important  internal  ones. 
On  account  of  variations  in  size  and  situation  of  the  radial 
arteries  both  should  be  examined.  It  must  also  be  remem- 
bered that  the  excessive  deposition  of  adipose,  or  the  pres- 
ence of  edema,  may  prevent  successful  examination  of  the 
radial  arteries.  It  seldom  happens,  however,  that  radial 
sclerosis  is  diagnosed  when  absent,  the  error  is  usually  on 
the  other  side. 

'  Judson  Daland,  Monthly  Cyd.  Pract.  Med.,  Vol.  x,  p.  145,  1907. 


ARTERIOSCLEROSIS  277 

It  is  important  to  separate  true  sclerosis  from  pure  hyper- 
tension as  the  impression  under  the  finger  in  these  two 
conditions  is  quite  similar.  Arterial  spasm  usually  occurs 
in  the  young  and  palpation  of  the  vessel  wall  reveals  a 
vessel  which  feels  thicker  and  smaller  than  normal,  while 
the  lumen  appears  to  be  diminished.  The  common  causes 
of  this  condition  are  (1)  acute  uremia,  occurring  in  the 
course  of  acute  parenchymatous  nephritis,  as  in  scarlet  fever 
and  similar  infectious  processes;  (2)  in  certain  cases  of 
severe  acute  intestinal  toxemia;  (3)  in  certain  cases  of 
irritating  chemical  poisoning. 

Apart  from  the  result  obtained  from  palpation,  the  car- 
diac and  renal  signs  of  arterial  spasm  may  exactly  simulate 
arteriosclerosis  and  we  are  therefore  compelled  to  rely  upon 
the  knowledge  of  the  cause  and  duration  of  the  condition 
to  determine  the  degree  of  arterial  change. 

Reliance  should  not  be  placed  upon  the  radial  arteries 
alone,  but  for  diagnostic  purposes  we  should  use  the  tem- 
poral, the  carotid,  the  brachial,  the  abdominal  aorta,  the 
femoral  and  the  dorsalis  pedis. 

Changes  in  Blood-pressure. — Having  determined  the 
condition  of  the  blood-vessels,  blood-pressure  tests  may 
then  be  applied.  In  the  presence  of  arteriosclerosis  the 
systolic  pressure  will  be  found  above  that  determined  as 
normal  for  the  age  of  the  individual.  This  elevation  need 
not  be  great.  A  continued  hypertension  of  20  or  30  mm. 
unless  explained  upon  other  grounds  should  be  considered 
pathologic  and  call  for  explanation.  It  should,  however, 
be  remembered  that  cases  will  be  met  having  very  hard 
and  firm  peripheral  vessels  yet  which  have  a  normal  or 
subnormal  systolic  blood-pressure. 


278 


BLOOD-PBESSURE 


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Fig.  53. — Arteriosclerosis.  Aged  forty-three.  Clerk.  Complains  of  per- 
sistent headaches  for  a  period  of  about  three  years,  not  relieved  by  glasses. 
Prior  to  the  first  observation,  he  is  said  to  have  had  a  pressure  of  about  200. 
Attempts  to  reduce  this  by  appropriate  electrical  treatment  were  unsuccess- 
ful. The  headache  is  characteristically  one  of  arteriosclerosis,  coming  on  in 
the  early  morning,  usually  waking  the  patient  between  5  and  6,  and  wearing 


i 


ARTERIOSCLEROSIS  279 

I  distinctly  remember  one  case  of  over  fifty  years  of  age 
having  the  most  rigid  and  pipe-stem  radials  that  I  have 
ever  palpated,  yet  at  no  time  was  the  systolic  pressure  found 
to  be  over  100  mm.  Hg.  Again  the  hypertensive  effect 
of  arteriosclerosis  may  be  counteracted  by  the  hypotensive 
effect  of  an  associated  thyroid  disease  or  a  deranged  ad- 
renal system,  as  in  Addison's  disease  (see  page  216). 

A  comparison  of  the  systolic  and  diastolic  pressures  and 
an  estimation  of  the  pulse  pressure  is  of  distinct  value  in 
the  study  of  all  cases.  The  physical  changes  produced  in 
the  dynamics  of  the  circulation  by  the  less  elastic  vessel 
walls,  will  in  the  presence  of  a  normal  heart  show  an  in- 
creased pressure,  often  as  high  as  60  and  occasionally  100 
or  more,  as  the  advanced  and  extreme  cases  are  met  (see 
Fig.  53). 

Examination  of  the  heart  in  pure  early  arteriosclerosis 
(before  the  kidney  has  become  much  damaged)  will  reveal 

off  during  the  day.  Is  usually  left-sided  extending  from  behind  the  ear  to 
the  frontal  region  and  involving  the  eyes. 

Has  been  an  excessive  alcohol  user,  but  has  during  the  past  several  years 
totally  abstained. 

Dietetic  and  hygienic  treatment  accomplished  much  in  the  relief  of  the 
headache  without  greatly  affecting  blood-pressure.  The  drug  medication 
was  entirely  incidental  to  a  condition  of  the  stomach,  bowels  and  inter- 
current colds.  The  phthalein  test  on  9-24-'15  gave  a  50  per  cent,  output  in 
the  first  two  hours.  The  urine  has  occasionally  shown  a  trace  of  albumin, 
has  been  of  normal  specific  gravity  and  has  variably  shown  casts  both  hya- 
line and  granular  and  a  few  blood  cells. 

The  depression  in  systolic  pressure  between  (A)  and  {B)  was  incident  to  a 
development  of  an  acute  mastoiditis  necessitating  confinement  to  bed. 
At  (C)  the  patient  presented  with  signs  of  pulmonary  edema  which  was 
promptly  relieved  by  appropriate  treatment,  coincident  with  a  reduction  in 
both  systolic  and  pulse  pressure. 

From  a  survey  of  this  chart  it  is  evident  that  the  condition  contributed  to 
the  high  pressure  is  progressing  in  spite  of  measures  directed  toward  its 
relief  and  it  is  only  a  question  of  time,  possibly  short,  when  this  patient  will 
succumb  to  the  effects  of  an  ever-increasing  systolic  and  pulse  pressure. 


280  BLOOD-PRESSURE 

some  slight  accentuation  of  the  second  aortic  sound,  and 
a  compensatory  hypertrophy,  although  the  studies  of 
Romberg  and  Hasenfeld^  found  hypertrophy  of  the  left 
ventricle  in  only  a  small  proportion  of  cases  of  arterio- 
sclerosis before  an  associated  nephritis  had  developed. 

The  temperature,  as  is  the  case  in  most  chronic  diseases, 
will  usually  be  found  subnormal,  although  StengeP  calls 
attention  to  the  occurrence  of  continued  fever  in  certain 
cases,  and  he  holds  that  when  there  is  no  other  assignable 
cause  for  the  fever,  it  is  probably  due  to  the  arteriosclerotic 
process. 

The  Digestive  Tract. — Examination  of  the  digestive 
tract  will  often  reveal  slight  departures  from  normal  often 
dating  back  for  many  years.  The  results  of  test-meal 
examinations  will  show  reduced  gastric  secretory  activity. 
There  is  usually  abdominal  distention  and  often  most 
obstinate  constipation. 

The  ocular  changes  found  in  arteriosclerosis  are  cork- 
screw retinal  artery  twigs,  a  dull  red  nerve  head  and  flatten- 
ing of  the  veins  at  the  arterial  crossings.  Sluggish  pupillary 
reaction  and  early  failure  of  accommodation. 

Pathognomonic  evidence  of  arteriosclerosis  will  be  found 
by  the  presence  of  most  or  all  of  the  following  ocular  signs: 

1.  Change  in  the  course  and  size  and  irregular  caliber  of 
the  arteries  and  of  the  veins,  the  latter  being  indented  at 
the  arterial  crossings. 

2.  Altered  vascular  reflexes,  such  as  more  brilliant 
central  light  streak  (silver  wire  artery). 

3.  Undue  fullness  of  the  perivascular  lymph-sheaths. 

1  DeiU.  Arch.  f.  klin.  Med.,  Vol.  lix,  1897,  p.  193. 

2  Medicine,  Detroit,  June,  1906. 


ARTERIOSCLEROSIS  281 

4.  Paleness  of  the  vessels. 
In  more  advanced  cases; 

5.  Faint  hemorrhages. 

6.  Retinal  haze,  more  marked  at  the  nerve  head. 

The  "red-hot"  eye  is  frequently  seen  in  arteriosclerosis 
particularly  in  the  presence  of  a  gouty  diathesis.  A  per- 
sistent asthenopia  and  atrophy  are  also  encountered. 

HertzelFs^  reaction  of  congestion  for  the  diagnosis  of 
arteriosclerosis  is  only  mentioned  to  be  condemned,  for 
any  procedure  which  contemplates  complete  interruption 
of  the  circulation  in  the  extremities  with  a  consequent  rise 
of  60  or  more  millimeters  of  mercury  in  an  arteriosclerotic, 
is  to  say  the  least  hazardous  in  the  extreme. 

^  C.  Hertzell,  Berl.  klin.  Wochen.,  Mar.  24,  1913. 


CHAPTER  XVIII 

NEPHRITIC  HYPERTENSION  AND  CHRONIC 
NEPHRITIS 

Etiology. — The  question  of  the  etiology  of  the  several  dis- 
tinct types  of  chronic  Bright's  disease  such  as  chronic  par- 
enchymatous nephritis,  chronic  interstitial  nephritis  and 
syphilitic  nephritis  is  still  under  discussion.  A  careful 
review  of  the  data  at  hand  shows  that  the  last  word  has 
not  yet  been  said,  neither  has  it  been  settled  whether  the 
arteriovascular  changes  are  primary  or  secondary  to  the 
renal  changes.  There  being  much  equally  reliable  evidence 
pointing  in  both  directions,  it  would  seem  expedient  to 
assume  a  middle  position  and  admit  for  the  present,  at 
least,  that  in  view  of  the  various  and  diversified  causes  of 
arteriosclerosis  and  nephritis,  it  is  probable  that  the  arterial 
process  may  be  primary  in  some  cases,  the  nephritic  in- 
volvement the  first  pathologic  change  in  others,  while  in 
a  third  group  the  two  may  run  parallel  courses.  This 
position  is  strengthened  by  the  undoubted  fact  that  the 
majority  of  post-mortem  reports,  as  well  as  the  bulk  of 
experimental  evidence,  tend  to  show  that  either  condition 
may  exist  independently  of  the  other,  although  usually 
they  are  found  combined. 

A  dissenting  opinion  is  that  of  McCrae^  who  beheves  that, 

*  McCrae  in  Osier's  "Modern  Medicine,"  1909,  vi. 
282 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        283 

neither  chronic  parenchymatous  nephritis  nor  chronic  inter- 
stitial nephritis  ever  exists  alone,  in  as  much  as  "inter- 
stitial change  never  exists  without  an  accompanying 
parenchymatous  change  and  parenchymatous  change  can- 
not exist  long  without  some  interstitial  alteration  following 
or  accompanying  it."  He  doubts  the  development  of  a 
primary  contracted  kidney. 

Strumpell  considers  chronic  interstitial  nephritis  as  an 
atrophy  of  the  parenchyma  which  begins  in  a  previously 
healthy  kidney,  and  not  necessarily  the  ultimate  termina- 
tion of  a  chronic  diffuse  nephritis,  though  he  describes  a 
secondary  contracted  kidney  which  he  considers  simply  a 
more  advanced  form  of  chronic  diffuse  nephritis. 

Admitting  the  possibility  of  an  occasional  pure  case  of 
either  type,  we  are  forced  to  admit,  since  both  morbid 
anatomists  and  pathologists  are  far  from  unanimous  in 
their  descriptions  of  the  various  types  and  groups  of  chronic 
nephritis  and  as  physicians  are  not  always  able  to  make  a 
differentiation  that  is  satisfactory  from  a  clinical  point  of 
view  or  that  holds  good  in  the  light  of  post-mortem  revela- 
tions, that  by  far  the  largest  number  of  cases  met  in  actual 
practice  belong  to  what  Dieulafoy^  calls  mixed  nephritis 
and  that  these  constitute  the  common  form  of  chronic 
Bright's  disease. 

Concerning  the  relationship  of  arteriosclerosis  to  chronic 
Bright's  disease,  we  are  just  as  much  in  the  dark,  because, 
if  we  accept  the  general  theory  that  the  lesions  of  chronic 
contracted  kidney  are  due  to  a  local  form  of  arteriosclerosis, 
this  does  not  explain  all  the  cases  of  chronic  nephritis  in 
which  the  arteries  chiefly  are  affected,  nor  does  it  fit  in 

1  "Text-book  of  Medicine,"  1911,  ii. 


284  BLOOD-PRESSURE 

with  the  fact  that  we  may  have  extensive  arteriosclerotic 
changes  with  very  Uttle  renal  change. 

In  the  light  of  this  continued  uncertainty  it  would  seem 
best,  from  the  view  point  of  a  clinician,  to  subordinate 
these  degenerative  lesions,  not  only  in  the  kidneys  but  also 
in  other  organs  commonly  affected,  to  the  one  prime  or 
provocative  cause  (as  gout,  lead  infections,  heredity,  etc.) 
(see  page  261). 

It  is  also  a  well-known  clinical  fact  that  it  is  rare  to  find 
a  case  of  chronic  interstitial  nephritis,  which  permits  of  a 
fairly  definite  diagnosis,  in  which  the  cardiovascular  changes 
are  not  more  or  less  well  developed. 

We  have  then,  in  the  average  case,  a  pathologic  condition 
which  involves  jointly,  chronic  changes  in  the  arteries,  in 
the  kidneys  and  in  the  heart;  in  the  study  of  which  our 
diagnostic  effort  is  directed,  first,  toward  placing  the  chief 
responsibility  and  second,  toward  arresting  the  process  or 
discovering  and  rendering  inactive  the  cause  or  causes. 
The  solution  of  this  problem  is  not  simple,  neither  is  it 
always  possible,  so  that  we  may  be  forced  to  be  content 
with  the  general  diagnosis  of  cardiovascular  renal  disease; 
because  it  is  now  accepted  that  (a)  arteriosclerosis  may 
cause  the  arteriosclerotic  kidney,  (6)  contracted  kidney 
may  cause  arteriosclerosis,  or  (c)  both  may  result  from  a 
common  cause.  However  this  may  be,  it  is  evident  that 
the  provocative  substance  reaches  the  kidneys  through  the 
blood-stream,  which  fact  has  probably  led  Anders  and 
others  to  consider  chronic  interstitial  nephritis  as  but  one 
lesion  of  a  generalized  process  of  fibrosis,  in  which  no  one 
can  predetermine  what  organ  or  organs  will  first  succumb 
to  the  toxic  irritant. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        285 

Despite  many  opinions  to  the  contrary,  it  would  seem 
reasonable  to  believe  that  no  matter  what  the  cause  may 
be,  hypertension  is  the  primary  trouble,  that  this  results 
in  a  dilatation  of  the  arterial  walls,  incident  to  the  increase 
in  lateral  pressure;  while  nature  in  an  effort  to  combat  the 
abnormal  dilatation  produces  a  gradual  thickening  in  the 
arterial  wall  which  is  the  first  step  in  the  production  of 
arteriosclerosis.  Either  coincidentally  or  immediately  fol- 
lowing this,  the  increased  pressure  and  the  change  in  the 
arterial  walls  demand  additional  work  of  the  heart,  to 
provide  which  the  heart  hypertrophies,  thereby  setting  up 
a  portion  of  a  vicious  circle  which  is  completed  when  the 
arteries  and  arterioles  of  the  kidneys  take  part  in  the 
degenerative  process  which  leads  to  an  arteriosclerotic,  or 
chronically  contracted  kidney.  This  theory  is  further 
strengthened  by  the  fact  that  it  is  reasonable  to  suppose, 
and  has  been  experimentally  demonstrated,  that  the  toxins 
which  are  directly  responsible  for  the  rise  in  blood-pressure 
at  the  same  time  exert  an  injurious  effect  upon  the  arterial 
walls  and  that,  where  the  action  of  these  toxins  is  long  con- 
tinued, the  persistent  hypertension  becomes  a  permanent 
high  blood-pressure,  with  the  development  of  general 
arteriocapillary  sclerosis,  as  was  first  suggested  by  Gull 
and  Sutton  in  1872.^  Again,  it  is  now  generally  believed 
that  no  marked  general  arteriosclerotic  changes  can  exist 
without  more  or  less  involvement  of  the  kidneys.  Whether 
the  renal  lesion  will  be  the  predominating  factor  depends 
entirely  on  the  original  integrity  of  the  kidneys,  and  their 
power  to  resist  the  effect  of  the  toxin  which  primarily 
caused  the  vascular  change. 

1  Med.  Chir.  Trans.,  1872,  Iv. 


286  BLOOD-PRESSURE 

THEORY  OF  THE  MECHANISM  OF  THE  PRODUCTION  OF  HIGH 
BLOOD-PRESSURE 

Several  theories  have  been  advanced  to  explain  the  rela- 
tion of  the  kidney  to  the  high  blood-pressure  in  nephritis, 
none  of  which  have  been  fully  accepted  as  conclusive. 

We  may  conveniently  divide  these  theories  into: 

(a)  The  mechanical. 

(6)  The  chemical. 

(c)   The  retentive. 

(a)  Mechanical  Theory. — There  are  still  many  supporters 
of  the  old  Traube  and  Cohnheim  theory,  which  held 
that  mechanical  interference  with  the  blood  flow  in  the 
kidney  is  responsible  for  the  high  blood-pressure  in  nephri- 
tis. Failure  to  produce  increased  blood-pressure  by  ligat- 
ing  the  renal  arteries  or  by  the  experimental  production 
of  multiple  renal  emboli  does  not  disprove  this  theory.  It 
has  been  suggested  that  the  increase  in  blood-pressure  is 
a  protective  effort  on  the  part  of  nature  to  promote  an 
adequate  kidney  function  in  the  face  of  mechanical  de- 
ficiency resulting  from  glomerular  destruction.  This  theory 
is  hardly  tenable  in  the  face  of  the  fact  that  in  amyloid 
disease  of  the  kidneys  (a  glomerular  affection)  the  blood- 
pressure  is  rarely  affected  and  the  heart  not  often  hyper- 
trophied. 

(6)  Chemical  Theory. — This  theory  is  complicated,  in 
that  it  attributes  the  high  blood-pressure  to  the  activity 
of  chemical  substances  derived  from  several  sources  result- 
ing in  (1)  a  reduced  or  altered  renal  elimination,  (2)  a  dis- 
turbance of  internal  secretion,  (3)  toxic  substances  liberated 
by  the  diseased  kidneys. 

1.  In  an  effort  to  prove  the  reduced  elimination  theory 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        287 

Pearce^  found  that  extracts  of  the  kidneys  of  dogs,  having 
experimental  uranium  or  chromium  nephritis,  when  the 
urine  showed  none  of  the  normally  present  depressor  sub- 
stance, had  no  pressor  effect,  and  that  it  is  therefore  im- 
probable that  the  kidneys  are  responsible  for  a  pressor 
substance  of  importance  in  the  pathology  of  cardiovascular 
and  renal  disturbances. 

2.  The  hyperperformance  of  the  adrenals  has  long  been 
advanced  as  the  probable  cause  of  a  continued  high  pres- 
sure. Recent  investigations,  however,  have  failed  to  dem- 
onstrate, in  the  patients  with  hypertension,  any  increase 
in  the  epinephrin  in  the  circulating  blood.  Furthermore, 
R.  G.  Hoskins  and  C.  W.  McClure^  state  that  the  primary 
affect  of  adrenalin  administered  intravenously  is  a  lowering 
of  blood-pressure  and  that  the  quantity  required  to  cause 
(experimentally)  a  minimum  hypertension  is  several  times 
the  quantity  that  they  were  able  to  demonstrate  experi- 
mentally in  the  circulating  blood. 

Recently  Voegtlin  and  Macht^  after  reviewing  the 
evidence  for  and  against  the  direct  relation  of  epinephrin 
in  the  blood-stream  to  the  blood-pressure  level,  agree  with 
O'Connor^  that  there  is  some  other  vasoconstrictor  sub- 
stance in  the  blood.  This  they  believe  to  be  the  crystalline 
substance  isolated  and  described  by  Zucker  and  Stewart^ 
and  by  Kaufman.*'  They  have  been  able  to  isolate  the 
substance  already  described  by  these  observers  and  to  make 

1  Arch.  Int.  Med.,  May,  1912. 

2  Arch.  Int.  Med.,  October,  1912,  x,  4. 

3  Carl  Voegtlin  and  David  I.  Macht,  Jour.  A.  M.  A.,  Dec.  13,  1913,  Vol. 
xli,  24,  p.  2136. 

*  Arch.  f.  exper.  Path.  u.  Pharmakol.,  1911,  Ixiii,  195. 

6  Jour.  Exp.  Med.,  1913,  xvii,  152. 

6  Centralbl.  f.  Physiol,  1913,  xxvii,  5270. 


288 


BLOOD-PRESSURE 


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Fig.  54. — Male.  Aged  thirty-nine.  Acute  toxic  irritation  of  kidneys. 
This  patient  has  been  personally  known  to  the  author  for  fifteen  years 
and  has  enjoyed  particularly  good  health. 

At  (A)  examined  and  at  that  time  stated  that  he  had  not  felt  well  for 
about  two  weeks  and  dated  his  trouble  from  an  attack  of  food  poisoning  with 
moderate  prostration  and  diarrhea.  This  was  followed  by  a  sore  throat 
which  developed  into  tonsillitis.  He  complained  of  feeling  tired  and  weak, 
although  he  continued  work.  Later  his  hands  became  swollen,  his  shoes 
tight  and  a  persistent  headache  developed  which  was  intense.  Nausea  was 
persistent  and  during  the  preceding  twelve  hours  all  food  had  been  vomited. 
Examination  showed  an  abnormally  high  systolic  pressure  and  large  pulse 
pressure,  an  irregular  pulse,  an  accentuated  aortic  second  sound,  a  normal 
temperature,  scanty  urine  of  high  specific  gravity,  a  large  amount  of  albumen, 
an  occasional  hyaline  cast  and  a  few  red  blood  cells.     In  spite  of  restricted 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        289 

a  study  of  its  chemical,  physical  and  physiologic  properties, 
from  which  they  feel  justified  in  regarding  it  as  a  definite 
chemical  substance,  with  a  pharmacologic  action  different 
from  epinephrin,  and  from  any  other  body  hitherto  ob- 
tained from  the  blood.  Considerable  importance  attaches 
to  this  discovery,  as  it  appears  that  this  substance  may  be 
the  long-sought  cause  of  high  blood-pressure  in  cardio- 
vascular-renal disease. 

M.  Hagelberg^  found  a  high  sugar  content  of  the  blood 
in  twenty-six  cases  which  he  studied.  He  suggests  that 
this  condition  may  be  the  cause  of  the  disease  and  that  it 
may  indirectly  be  due  to  the  supposed  increase  in  epinephrin 
content  in  the  blood,  whereas  A.  Farini^  found  no  relation 
between  the  amount  of  excess  of  sugar  in  the  circulating 
blood  and  the  presence  of  arteriosclerosis  or  chronic 
nephritis. 

3.  One  of  the  most  important  factors  in  the  production 

diet  and  of  eliminative  measures  the  pressure  continued  to  rise  for  a  week, 
although  the  headache  and  nausea  were  promptly  reheved  at  {B). 

The  phthalein  output  at  (C)  was:  first  hour  47  per  cent.,  second  hour  36 
per  cent.,  while  the  urinary  output  had  greatly  increased  and  the  albumen 
was  reduced. 

At  (D)  the  patient  expressed  himseK  as  feehng  perfectly  well  but  was 
still  confined  to  bed  on  account  of  evidence  of  cardiac  over-action  as  shown 
by  the  pulse  pressure.  At  this  time  the  urine  had  returned  to  a  normal 
specific  gravity,  the  albumen  was  reduced  to  a  trace  and  there  were  still 
occasional  hyaline  casts  and  cylindroids,  and  an  occasional  red  blood  cell. 

At  (E)  the  patient  resumed  moderate  activity  and  was  symptom  free. 

At  (F)  he  returned  to  business  and  the  embargo  on  meat  was  removed  and 
the  patient  dismissed. 

Subsequently  the  slight  rise  in  pressure  is  explained  by  increased  physical 
activity,  as  there  has  been  no  evidence  of  the  original  symptoms  while 
urine  remains  normal.  The  patient  has  reported  recently  that  he  is  in 
excellent  condition. 


19 


»  Berl.  klin.  Wochen.,  Sept.  20,  1912,  xlix,  40. 

*  Gazet.  d.  Ospedali  e  dee  Cliniche,  August,  1913,  92,  p.  951. 


290  BLOOD-PRESSURE 

of  arteriosclerosis  is  the  continued  excretion,  by  the  kidneys, 
of  toxins  coming  from  abnormal  proteid  metabolism,  in 
the  digestive  tract  and  in  the  liver  (Fig.  54) — substances 
which  have  long  been  considered  to  be  important  factors 
in  the  production  of  contracted  kidney  and  of  arteriosclero- 
sis. Indol  has  been  recently  shown  by  Dratschiniski^  to 
be  of  great  importance  in  this  connection.  Other  experi- 
mental evidence  has  shown  that  to  produce  polyuria  and 
increased  blood-pressure  by  mechanical  destruction  of 
kidney  structure,  about  two-thirds  of  the  total  kidney 
substance  must  be  removed  and  that  it  is  impossible  to 
say  whether  these  results  are  due  to  lessened  elimination 
or  mechanical  interference  with  the  renal  blood-supply, 
and  further,  that  while  in  uremia  there  is  usually  nitrogenous 
retention,  it  has  not  been  shown  that  such  retention  is 
responsible  for  the  increased  blood-pressure. 

(c)  Retention  Theory. — E.  Krautenberg^  demonstrated 
experimentally  the  production  of  a  chronic  nephritis  in 
rabbits  by  ligating  the  ureter.  Autopsy  on  such  animals, 
often  alive  twelve  to  eighteen  months  after  the  ligation, 
always  showed  extensive  sclerosis  and  aneurism  of  the 
aorta,  which  this  observer  attributes  to  blood-pressure 
changes  resulting  from  the  kidney  degeneration  caused  by 
the  ligation. 

H.  H.  Mills^  advances  the  theory  and  cites  cases  in  which 
he  found  marked  diminution  in  the  urea  excretion  in  chronic 
nephritis  as  compared  with  a  number  of  normal  cases  in 
which  the  pressure  and  kidneys  appeared  normal. 

The  attempt  has  been  made  to  explain  high  blood-pres- 

^  Annul,  de  I'Instit.  Pasteur,  June,  1912,  xxvi,  6. 
2  Deutsch.  Med.  Wochen.,  March  25,  xxxvi,  12. 
2  N.  Y.  Med.  Jour.,  Aug.  20,  1910. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC   NEPHRITIS        291 


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Fig.  55. — Acute  parenchymatous  nephritis.  Male.  Aged  twenty-nine. 
The  first  evidence  of  this  condition  was  the  sudden  development  of  almost 
complete  blindness,  due  to  extensive  retinal  hemorrhage  as  shown  by  oph- 
thalmoscopic examination.  Heart  rapidly  became  over-active  and  dilated. 
Cardiac  second-soimds  very  sharp  and  a  systolic  murmur  developed.  Urin- 
alysis showed  an  immense  amount  of  albumin,  all  varieties  of  casts  and 
blood  cells  which  persisted.  Cardiac  embarrassment  was  the  chief  symptom 
and  required  morphin  for  its  relief.  Late  in  the  disease  dyspnea  was  very 
annoying.  At  the  time  of  the  last  observation  the  urine  was  again  scant  and 
almost  solid  with  albumin.  Stimulating  treatment  and  hot  packs  availed 
only  for  a  short  time  (A  to  B). 

At  (C)  the  patient  passed  out  of  observation  and  died  in  less  than  two 
weeks. 


292  BLOOD-PRESSURE 

sure  through  retention  of  waste,  ordinarily  eUminated 
through  the  kidney.  None  of  the  substances,  however, 
which  are  eUniinated  by  the  kidney  have  a  pressor  action 
when  injected  into  animals. 

Von  Bie^  cites  data  to  show  that  there  seems  to  be  no 
uniform  relation  between  the  blood-pressure  and  anatomic 
conditions  of  the  kidney.  He  believes  the  high  pressure 
is  the  primary  disturbance,  and  that  arterial,  nephritic 
and  cardiac  affections  occur  only  secondarily  (see  Fig.  55). 

PATHOLOGY  OF  NEPHRITIS 

The  pathology  of  chronic  nephritis  is  primarily  that  of 
the  conditions  incident  to  alterations  in  the  kidney  struc- 
ture, and  secondarily  (as  usually  seen  by  the  clinician  and 
the  pathologist)  that  of  the  many  secondary  degenerations 
incident  to  and  largely  dependent  upon  reduced  renal 
function  and  the  changes  wrought  throughout  the  body  by 
the  high  blood-pressure,  which  is  the  common  accompani- 
ment of  the  disease  and  which  develops  soon  after  its 
inception. 

Concerning  the  earlier  changes  very  little  of  a  definite 
nature  is  known,  and  what  is  believed  is  more  the  product 
of  conjecture,  partially  supported  by  animal  experimenta- 
tion, than  of  actual  clinical  and  pathologic  study. 

The  pathology  of  moderately  well-developed  and  of 
advanced  nephritis,  with  persistent  high  blood-pressure, 
is  so  protein  in  its  manifestation,  involving  practically  every 
organ  of  the  body,  that  it  would  be  impossible  as  well  as 
superfluous  to  enter  into  a  discussion  of  it  here. 

^  Ugeskrift  f.  Slaeger,  Mar.  4,  Ixxvii,  9. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        293 

The  post-mortem  pathology  is  of  great  interest,  chiefly 
because  of  the  Hght  which  it  throws  upon  the  cUnical  mani- 
festations, and  by  serving  at  once  as  a  check  on  clinical 
diagnosis  and  as  a  spur  to  more  careful  and  painstaking 
study,  in  the  hope  that  greater  clinical  ability  will  eventu- 
ally decrease  the  percentage  of  error  which  now  exists  in 
the  clinical  diagnosis,  as  shown  in  the  light  of  necropsy 
findings. 

The  most  important  single  result  of  post-mortem  path- 
ology has  been  to  demonstrate  the  almost  invariable  rela- 
tion of  very  high  blood-pressures  to  chronic  kidney  changes. 
Thus  Joseph  L.  Miller^  reports  that,  in  Krehl's  clinic,  of 
the  cases  with  pressure  of  200  or  over,  87.4  per  cent, 
showed  definite  clinical  evidence  of  nephritis,  while  forty- 
two  of  the  forty-three  cases  coming  to  autopsy  showed 
definite  renal  involvement. 

J.  Fisher^  reports  a  review  of  550  cases  of  continuous 
high  pressure.  Of  the  cases  above  140,  62  per  cent,  showed 
nephritis,  while  of  the  cases  with  pressure  over  160,  80 
per  cent,  showed  nephritis.  Forty-two  cases  came  to 
autopsy,  all  of  which  showed  evidences  of  kidney  disease, 
even  those  where  there  had  been  no  clinical  evidence  of  it, 
though  congested  kidney  or  idiopathic  dilatation  of  the 
heart  had  been  diagnosed. 

Roger  L.  Lee^  reports  both  cUnical  and  pathologic 
(autopsy)  findings  in  fifty-three  cases  seen  in  the  wards  of 
Massachusetts  General  Hospital,  all  of  whom  showed 
systolic  blood-pressure  of  over  160.     He  found  high  pres- 

1  Jour.  A.  M.  A.,  Oct.  44,  1913,  Ivi,  14. 

2  Deutsch.  Arch.  f.  klin.  Med.,  cix,  No.  5. 

'  Jour.  A.  M.  A.,  Vol.  Ivii,  No.  15,  p.  1179. 


294  BLOOD-PRESSURE 

sure  associated  with  kidney  lesions  in  thirty-eight  cases 
or  71  per  cent.  Seven  who  showed  kidney  lesions  also  had 
a  systolic  blood-pressure  ranging  from  165  to  240  mm. 
Their  ages  were  between  twenty  and  forty-nine  years. 

High  blood-pressure  existed  with  arteriosclerosis  in 
thirty-seven  cases  or  69  per  cent.  General  arteriosclerosis 
was  associated  with  lesions  of  the  kidneys  in  twenty-eight 
cases  or  52  per  cent.  There  was  only  one  case  of  high 
pressure  with  arteriosclerosis  without  kidney,  cerebral,  or 
cardiac  lesion;  this  showed  only  hypertrophy  and  dilata- 
tion. The  patient  was  sixty  years  old  and  the  blood- 
pressure  was  210. 

Of  cases  with  high  blood-pressure  without  kidney  lesion, 
these  were  15  or  28  per  cent.  Among  these  seven  showed 
cerebral  lesions,  four  had  cerebral  hemorrhage  and  seven 
showed  cardiac  lesions.  The  blood-pressure  varied  from 
175  to  260. 

C.  Fiessenger,^  examined  150  patients  with  high  pressure, 
in  52  per  cent,  of  which  he  found  interstitial  nephritis. 

Theodore  C.  Janeway^  reports  500  cases  of  pressure  over 
170,  150  of  whom  have  died  and  concerning  which  the 
subsequent  history  and  the  cause  of  death  were  available 
in  100.  Of  these,  the  clinical  diagnosis  was  chronic 
nephritis  in  79  per  cent,  and  arteriosclerosis  4  per  cent. 
He  believes  that  these  four  cases  of  arteriosclerosis  should 
be  included  in  the  nephritics,  as  it  is  unlikely  that  such 
cases  can  persist  for  long  without  involving  the  kidney, 
and  because  autopsy  statistics  show  that  this  is  a  most 
frequently  overlooked  item  in  clinical  diagnosis. 

1  Bull,  de  I'Acad.  de  Med.,  Apr.  16,  1912,  Ixxvi,  No.  16. 
^Jour.  A.  M.  A.,  Dec.  14,  1912,  lix,  p.  2100. 


I 


NEPHRITIC    HYPERTENSION    AND    CHRONIC   NEPHRITIS        295 
Causes  of  Death  in  High-pressure  Cases  (Janeway) 

Per  cent. 

Gradual  cardiac  insufficiency 29 

Uremic  convulsions  or  sudden  coma 15 

Chronic  uremia 20 

Cerebral  apoplexy 14 

Acute  edema  of  the  lungs 4 

In  this  table,  which  is  only  partially  quoted  here,  as  the 
chief  interest  is  in  the  effect  of  this  condition  upon  the 
cardiovascular  and  renal  systems,  an  effort  was  made  to 
determine  the  primal  cause  of  the  fatal  issue,  though  other 
causes  were  not  uncommonly  associated  with  it,  such  as 
anemia,  pneumonia,  etc. 

SYMPTOMATOLOGY 

Signs  and  Symptoms. — Chronic  interstitial  nephritis  in 
its  well-developed  form  is  usually  the  result  of  a  gradually 
progressive  process,  leading  up  to  a  clinical  picture  which 
is  too  well  known  and  too  easily  recognized  to  require 
more  than  passing  comment.  It  is  particularly  the  early 
states  of  this  disease  with  which  we  are  concerned.  Our 
chief  effort  and  desire  is  to  reach  an  early  provisional 
diagnosis,  so  that  preventive  or  prophylactic  treatment 
may  be  instituted  at  a  time  when  proper  management 
may  be  reasonably  expected  to  arrest  the  progress  of  the 
degenerative  process  in  the  kidneys,  and  so  to  indefinitely 
prolong  the  individual's  period  of  usefulness  and  life  by 
protecting  the  arteries  and  heart  from  the  increasing  strain 
to  which  they  are  invariably  subjected,  and  which  in  a 
large  percentage  of  cases  contributes  largely  to  the  fatal 
outcome. 

Blood-pressure. — A  permanent  elevation  of  both  systolic 
and  diastolic  blood-pressure  is  the  most  prominent  and 


296 


BLOOD-PKESSURE 


characteristic    sign    of    well-developed    chronic    nephritis. 
Sawada^  states  that  he  has  never  seen  a  case  of  hyper- 


BLOOD  P>R£SSUR£  CHART 

CHART  NO ■ (q^ 

NAME  >Yvv/»  ..  C  V ^^^  ■  i  ,;• 

COLOR  Xlf . 

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OCCUPATION  •  •  •  ■. 

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Fig.  56. — Uremic  paralysis,  resulting  from  chronic  interstitial  nephritis. 
Treatment  consisted  of  hot  wet  packs,  nitroglycerin,  1  per  cent,  solution, 
1  minim  every  hour,  and  magnesium  sulphate.  Treatment  stopped  on 
December  1,  and  sodium  nitrite  substituted,  December  7,  nitrite  stopped, 
hot  packs  continued.  Following  sudden  rise  on  December  14,  thirty-minute 
pack,  2  minims  nitroglycerin,  repeated  every  two  hours,  resulted  in  pro- 
found fall  as  shown,  with  no  bad  effect.  Subsequent  treatment  consisted 
of  thirty-minute  vapor  baths  and  weekly  purge,  in  spite  of  which  there 
occurred  a  gradually  rising  pressure. 

tension  of  more  than  170  mm.  in  simple  arteriosclerosis. 
This  limit  has  been  so  frequently  and  conclusively  demon- 

»  Deutsch.  med.  Wochen.,  1904,  No.  30. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        297 

strated  to  be  a  safe  one  that  it  has  been  accepted  as 
standard,  and  is  now  used  by  most  observers.  Romberg^ 
considers  that  persistent  high  blood-pressure  in  a  suspected 
case  estabHshes  a  diagnosis  of  chronic  interstitial  nephritis. 
From  the  author's  experience,  in  the  light  of  post-mortem 
findings  it  seems  very  doubtful  whether  a  high  arterial 
pressure,  from  arteriosclerosis  or  any  other  cause,  can 
persist  over  a  long  period  of  time  without  giving  rise  to  the 
chronic  congestion  and  permanent  degenerative  changes 
in  the  kidneys,  with  a  clinical  picture  known  as  chronic 
Bright's  disease.  The  pressure  is  higher  than  that  seen 
usually  in  any  other  chronic  disease.  Sphygmomano- 
metric  observations  daily  confirm  this.  A  systolic  blood- 
pressure  of  more  than  200  mm.  (standard  cuff)  is  not 
uncommon,  and  I  have  seen  several  cases  with  a  reading 
of  over  300  mm.  (Fig.  56),  two  of  which  have  been 
under  observation  for  several  years  and  will  be  referred 
to  later.  A  second  salient  feature  of  this  disease  is  that 
the  diastolic  blood-pressure  does  not  show  a  proportionate 
elevation,  but  is  usually  from  60  to  90  mm.  lower,  thus 
making  an  increased  pulse  pressure  (evidence  of  unnecessary 
overwork  of  the  heart).  Factors  such  as  marked  general 
arteriosclerosis  or  aortic  regurgitation  will  further  accentu- 
ate these  changes. 

In  the  period  of  compensation  which  exists  throughout 
the  greater  part  of  the  disease  it  is  probable  that  several 
factors  are  separately  or  jointly  contributory  to  the  symp- 
tom of  heightened  blood-pressure.  Janeway^  has  grouped 
these  causes  under  these  heads: 

»  Kong.  f.  Int.  Med.,  1904,  No.  60,  p.  17. 

2  T.  C.  Janeway,  Am.  Jour.  Med.  Sci.,  May,  1913,  cxlv,  No.  5. 


298 


BLOOD-PRESSURE 


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Fig.  57. — Male.  Aged  sixty-seven.  Draughtsman.  Chronic  interstitial 
nephritis  following  chronic  alcoholism.  Chief  symptoms,  severe  head  pain, 
dimness  of  vision,  dizziness,  and  ringing  in  the  ears.  At  first  examination 
there  was  slight  general  edema,  some  pulmonary  edema,  drowsiness  and 
mental  confusion  with  a  typical  chronic  nephritic  urine.  The  effect  on 
pressure  from  (A)  to  (B)  was  accomplished  by  eliminative  measures  includ- 
ing hot  packs  and  purges  and  was  accompanied  by  complete  relief  from  all 
symptoms  except  physical  weakness.  Dyspnea  at  (C)  was  very  marked 
and  the  pulse  was  irregular  in  force  and  rhythm,  although  the  general  con- 
dition was  fairly  satisfactory.  Still  there  was  some  evidence  of  muscular 
weakness  and  paresthesia  in  the  left  arm.  (D)  Mild  return  of  uremic 
symptoms,  but  patient  did  not  lose  consciousness  and  promptly  re- 
sponded to  treatment.  At  (£')  patient  had  eleven  roots  extracted  under 
gas  without  untoward  effect.  At  {¥)  the  patient  was  still  in  good  condition 
and  practically  symptom  free,  although  he  has  given  up  both  work  and 
alcohol  and  is  taking  much  better  general  care  of  himself  than  heretofore. 
At  ((7)  there  is  nothing  in  the  record  to  show  that  the  patient  is  handicapped 
by  his  kidney  condition  and  is  at  present  living  a  fairly  regular,  quiet  life. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        299 

1.  Hypertension  may  arise  through  purely  quantitative 
reduction  of  kidney  substance  below  the  factor  of  safety. 
This  is  rare  and  probably  only  seen  in  the  later  stages 
of  the  disease,  where  myocardial  failure  contributes  largely 
to  this  lowered  functional  capacity. 

2.  It  may  arise  in  connection  with  some  unknown  intoxi- 
cation, which  causes  disturbances  of  the  central  nervous 
system  and  which  we  term  uremia.  This  intoxication  is 
not  one  of  retention,  in  a  strict  sense,  though  it  is  most 
commonly  present  in  those  cases  of  advanced  nephritis 
which  manifest  marked  nitrogen  retention.  Clinically  it 
may  be  associated  with  severe  acute  nephritis. 

3.  Continued  high  pressure  may  arise  from  primary 
irritability  of  the  vasoconstricting  mechanism  from 
unknown,  probably  extrarenal  causes,  which  lead  eventu- 
ally to  arteriolar  sclerosis.  In  this  type  the  disease  in 
the  kidney  is  the  sequence,  not  the  cause  of  the  generalized 
vascular  lesion. 

Systolic  and  Diastolic  Pressures. — It  is  thoroughly 
understood  that  any  condition  which  may  be  included 
under  the  head  of  nephritic  hypertension  or  nephritis 
presupposes  an  increased  blood-pressure,  although  this 
is  not  invariably  the  case.  The  variety  of  nephritis 
present  determines  to  a  degree  the  height  of  the  pressure, 
both  systolic  and  diastolic;  thus  I.  N.  Schwartzman^ 
analyzing  100  cases  of  various  forms  of  nephritis  found 
that  the  systolic  and  the  diastolic  pressures  were  both 
increased  in  uremia  (see  Fig.  57),  in  acute  parenchyma- 
tous, in  chronic  interstitial  and  in  the  combined  form  of 
nephritis. 

1  Russky  Vratch,  1915,  xiii,  No.  28. 


300 


BLOOD-PRESSURE 


We  believe  that  the  systoHc  and  diastolic  pressure  may 
be  increased  long  before  any  other  signs  of  chronic  nephritis 
develop,  and  that  high  blood-pressure  is  therefore  a  reliable 
early  sign  of  nephritis.  A  large  pulse  pressure  is  generally 
a  sign  of    good   compensation.^     At  the  termination    of 


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Fia.  58. — Chronic  interstitial  nephritis.  Male.  Aged  fifty-six.  This 
chart  shows  the  rapidity  of  the  rise  in  systolic  pressure  in  a  case  of  chronic 
interstitial  nephritis  and  myocarditis  in  a  patient  of  fifty-six  who  failed  to 
appreciate  the  necessity  of  care  or  treatment  and  was  willing  to,  as  he  said 
"take  his  chances."  Cardiac  dilatation  began  when  the  systolic  pressure 
reached  230  and  rapidly  advanced.  The  patient  died  in  an  attack  of  pul- 
monary edema  with  systolic  pressure  185.  Observations  before  1914 
recorded  on  chart  are  yearly  averages.  1914  observations  show  average 
systolic  pressures  by  months. 

a  case  of  chronic  nephritis,  the  systolic  pressure  tends  to 
fall,  due  to  diminished  cardiac  activity  and  the  diastolic 
pressure  increases.  This  is  usually  a  grave  sign,  pointing 
to  myocardial  failure  (see  Fig.  58).  The  pulse  pressure  in 
nephritis  is  invariably  increased  even  when  the  systolic 

^Warfield,  Am.  Jour.  Med.  Sci.,  cxlviii,  6,  1914. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        301 

is  not  materially  above  normal.  This  is  evidence  of  cardiac 
overactivity  plus  the  constitutional  effect  of  the  toxins 
which  have  primarily  produced  or  which  are  secondarily 
the  result  of  the  nephritis.  Marked  arterial  involvement 
increases  this  systolic  elevation ;  at  the  same  time  increased 
rigidity  holds  the  diastolic  pressure  down,  so  that  invariably 
the  pulse  pressure  is  increased.  The  degree  of  this  increase 
will  depend  upon  (a)  stage  of  the  disease,  (6)  the  degree  of 
cardiac  hypertrophy  and  compensation  and  (c)  the  degree 
and  extent  of  arterial  involvement. 

Considerable  study  has  been  made  of  the  relation  of 
pulse  pressure  to  urinary  excretion.  It  is  generally  be- 
lieved that  increased  pulse  pressure  increases  urinary  excre- 
tion and  Lawrence's^  studies  seem  to  prove  this;  on  the 
other  hand,  there  appears  to  be  no  relation  between  the 
height  of  systolic  and  diastolic  pressure  per  se  and  variations 
in  kidney  output,  although  an  increase  in  pulse  pressure 
accompanied  by  a  fall  in  systolic  pressure  appears  to  be 
followed  by  diuresis.  There  also  seems  to  be  a  relation 
between  the  normal  systolic,  diastolic  pulse  pressure  ratio 
which  normally  should  be  1-2-3,  so  that  whenever  the 
several  pressures  approach  this  normal  ratio,  irrespective 
of  the  height  of  systolic  pressure,  there  tends  to  be  a  rise 
in  urinary  excretion. 

Urinary  Findings  in  Nephritis. — While  text-books,  as  a 
general  rule,  present  comparative  columns  which  attempt 
to  show  clear  lines  of  differentiation  between  the  urinary 
findings  in  various  forms  of  chronic  nephritis,  it  is  clinically 
fully  appreciated  by  close  observers  that  such  a  differentia- 
tion is  probably  impossible.     A  single  urinalysis  is  practically 

^  Amer.  Jour.  Med.  Sci.,  September,  1912. 


302 


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Fia.  59. — Female.  Aged  fifty-one.  Uremic  hemiplegia.  The  first  obser- 
vations {A)  were  made  in  the  course  of  a  routine  examination  and  no  special 
circulatory  abnormality  noted.  The  observation  at  (5)  made  several 
hours  following  onset  of  the  right  hemiplegia  which  urinalysis  and  subse- 
quent developments  showed  to  be  uremic  in  origin.  Observation  at  (C)  was 
made  immediately  after  a  hot  pack.  Note  the  prompt  fall  in  systolic 
pressure  which  was  affected  to  a  greater  degree  than  was  the  pulse  pressure, 
which  remained  far  above  the  normal  ratio.  In  this  case  recovery  was 
extremely  slow  and  the  patient  was  left  with  some  right-sided  disability, 
although  there  has  been  no  recurrence  of  uremia.  That  the  relief  afforded 
is  only  temporary  is  suggested  by  the  marked  and  persistent  elevation  in 
pulse  pressure  together  with  the  tendency  of  the  systolic  pressure  to  rise  in 
spite  of  continued  active  treatment. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        303 

valueless,  whether  or  not  it  shows  any  pathologic  variation. 
Repeated  urinalyses  are  of  value  when  the  majority  are 
positive,  at  least  in  so  far  as  they  indicate  alterations  in 
kidney  function;  but  they  should  not  be  depended  upon 
where  the  findings  are  indefinite.  Neither  can  the  urinaly- 
ses be  depended  upon  to  assist  in  separating  the  clinical 
forms  of  chronic  nephritis  thus: 

Hewlett^  reports  fifty  cases  of  continued  high  pressure, 
usually  above  180,  eighteen  of  which  showed  no  urinary 
changes  other  than  rare  traces  of  albumin  or  occasional 
casts  (see  Fig.  59). 

Edema  of  nephritic  distribution  is  corroborative  evidence, 
but  as  it  is  rarely,  present  before  heart-muscle  failure  de- 
velops, it  cannot  be  depended  upon  for  an  early  diagnosis, 
nor  when  present  does  it  determine  the  degree  of  kidney 
impairment. 

Edema  of  the  lungs  may  occur  as  an  acute  condition  dur- 
ing the  course  of  a  chronic  nephritis.  It  may,  if  severe 
and  unrelieved,  constitute  the  terminal  process  in  the 
case. 

This  condition  is  frequently  preceded  by  an  abrupt  rise 
in  blood-pressure  which  if  detected  may  ward  off  the  attack 
by  the  institution  of  appropriate  measures. 

Cardiac  asthma  may  arise  under  the  same  circumstances 
and  it  is  contended  by  some^  that  the  acute  rise  in  blood- 
pressure  is  the  cause  of  the  cardiac  asthma.  Probably  the 
true  sequence  of  events  is  that  the  primary  disturbance 
is  vasomotor  and  cardiomotor,  the  insufficient  left  ventricle 
being   subordinate,    which    disturbs   the   proper   working 

^  Loc.  eit. 

*  K.  Petren  and  G.  Bergmark,  Berl.  klin.  Wochen.,  Dec.  17,  1910,  xlvi. 


304  BLOOD-PRESSURE 

balance  between    vascular    tension,    cardiac    action    and 
respiration. 

Ocular  signs  are  not  reliable  criteria  of  the  degree  of  • 
kidney  impairment.     They  may  appear  early  and  persist 
or  they  may  develop  late,  long  after  a  satisfactory  diagnosis 
has  been  established. 

The  subjective  symptoms  differ  in  no  way  from  those 
associated  with  arteriosclerosis  and  have  been  fully  dis- 
cussed under  that  head. 

The  cardiac  evidence,  often  dwelt  upon  so  extensively  in 

dissertations  on  chronic  nephritis,  are  not  truly  nephritic 

at  all,  as  they  are  dependent  wholly  upon  the  arterial 

condition,  and  when  present  are  purely  myocardial  signs 

and  of  myocardial  significance  and  should  be  given  this 

interpretation. 

DIAGNOSIS 

A  diagnostic  distinction  between  the  several  conditions 
grouped  under  the  general  head  of  nephritic  hypertension 
and  chronic  Bright's  disease  is  often  impossible.  This 
has  already  been  brought  out  in  the  paragraphs  devoted 
to  etiology  and  pathology.  The  difficulty  is  further 
increased  by  the  fact  that  cases  are  encountered  in  all 
periods  of  development  of  the  disease,  from  those  bordering 
on  pure  hypertension  to  those  in  the  advanced  stages,  in 
which  the  arterial  and  the  cardiac  involvement  may  com- 
pletely overshadow  the  renal. 

To  be  of  any  value,  any  effort  at  a  definite  diagnosis 
must  endeavor  to  estimate  the  degree  of  nephritic  involve- 
ment together  with  the  likelihood  of  a  uremia,  a  cerebral 
rupture  or  a  heart  muscle  failure;  as  it  is  upon  these  factors 
that  active  and  intelligent  treatment  must  be  based. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        305 

In  the  diagnosis  of  any  given  case  it  is  well  to  outline 
the  points  to  be  determined,  then  carefully  to  weigh  them 
one  against  the  other  in  the  final  analysis.  Roughly  the 
subject  divides  itself  into  a  consideration  of  (a)  the  general 
physical  condition;  (6)  the  urinary  findings;  (c)  the  cardiac 
adequacy;  (d)  the  arterial  involvement;  (e)  the  blood- 
pressure  picture;  (/)  the  renal  functional  efficiency;  and  (g) 
the  ocular  manifestations. 

(a)  The  General  Physical  Condition. — Much  can  be 
determined  by  a  careful  physical  examination  and  a  thor- 
ough history  that  throws  light  upon  the  patient's  general 
efiiciency,  including  mentality,  assimilation,  nurtrition, 
and  general  muscular  development. 

(6)  The  Urinary  Findings. — In  parenchymatous  nephritis 
the  urine  picture  is  very  similar  to  that  of  acute  Bright's 
disease  in  which  the  amount  of  urine  is  scant,  of  high  specific 
gravity,  with  a  relatively  large  albumin  content,  a  variety 
of  casts;  and  differing  from  it  only  in  the  usual  absence  of 
blood  casts,  though  there  may  be  an  occasional  red  cell, 
together  with  hyaline  and  epithelial  casts.  Chronic  inter- 
stitial nephritis  and  contracted  kidney  show  increased 
volume  of  urine  with  low  specific  gravity,  a  scant  or  absent 
albumin  reaction,  while  hyaline  and  granular  casts  are 
usually  found,  if  diligently  sought,  but  are  often  over- 
looked in  routine  examination.  In  the  examination  of 
single  specimens  occasional  red  cells  and  epithelia  may  be 
found. 

(c)  Cardiac  Efficiency. — The  functional  capacity  of  the 
kidneys  in  cases  coming  under  this  head  is  almost  entirely 
dependent  upon  cardiac  efficiency,  as  measured  by  the 
ability  of  the  heart  to  maintain  a  normal  circulation  against 

20 


306 


BLOOD-PRESSURE 


the  elevated  blood-pressure  which  is  the  result  of  general 
arterial  involvement  including  its  immediate  effect  on  heart- 
muscle  nutrition.  A  high  pressure  with  extensive  arterial 
involvement  may  present  a  better  picture  in  the  presence 
of  an  hypertrophied  and  muscularly  competent  heart  than 


Fig.  60. — Female.  Aged  fifty-eight.  High-grade  chronic  interstitial 
nephritis  of  many  years  standing.  Has  had  several  attacks  of  chronic  uremia 
with  tendency  to  muscular  weakness  on  left  side.  The  case,  which  has 
been  under  continuous  observation  for  a  period  of  five  years,  shows  the 
most  consistently  high  systolic  pressure  ever  encountered  by  the  author. 

At  the  last  observation,  both  symptomatically  and  by  physical  examina- 
tion, the  patient  appears  to  be  in  a  generally  better  condition  than  in  1910. 
The  urine  still  shows  increased  volume,  reduced  specific  gravity,  occasional 
granular  and  hyaline  casts  and  traces  of  albumin. 


a  case  showing  less  arterial  involvement  and  a  lower  pressure 
accompanied  by  a  poor  myocardium.  Therefore  it  is  impor- 
tant in  every  case  (see Fig.  60),  not  only  at  the  first  examina- 
tion but  during  the  subsequent  course,  to  follow  closely 
the  muscular  efficiency  of  the  heart  in  relation  to  the  handi- 
cap under  which  it  is  operating. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS        307 

(d)  Arterial  Involvement. — We  have  seen  that  arterial 
involvement,  as  demonstrated  by  the  examination  of 
superficial  vessels,  is  not  always  a  safe  criterion  upon  which 
to  judge  the  degree  of  renal  change.  Arterial  involvement 
may  be  very  irregular  in  its  distribution  and  we  are  not 
justified  in  condemning  the  kidneys  upon  the  evidence 
offered  by  a  study  of  the  superficial  branches  of  the  arterial 
tree.  It  is  also  recognized  that  marked  superficial  involve- 
ment may  occur  without  marked  elevation  of  blood-pressure; 
at  the  same  time  we  do  not  believe  that  a  blood-pres- 
sure persistently  of  200  or  more  can  exist  without  some 
degree  of  general  arterial  and  renal  involvement. 

(e)  Blood-pressure. — It  has  just  been  stated  that  the 
majority  of  observers  now  hold  that  a  systolic  pressure  of 
over  170  is  gravely  suspicious,  that  a  systolic  pressure  of 
persistently  200  or  more  is  almost  conclusive  evidence  of 
kidney  involvement  (see  Fig.  60).  This,  together  with  a 
continuously  increased  pulse  pressure,  may  be  accepted  as 
evidence  of  renal  involvement  per  se,  while  the  higher  the 
systolic  pressure  and  the  longer  the  duration  of  the  high 
pressure  the  more  likely  is  this  to  be  true. 

(/)  Renal  Functional  Efficiency. — However  attractive  it 
may  appear,  from  the  scientific  point  of  view,  to  estimate 
the  degree  to  which  the  anatomic  elements  of  the  kidney  are 
involved,  it  would  seem  that  the  mixed  type  of  nephritis, 
so  frequently  encountered  clinically,  practically  disposes  of 
any  attempt  to  arrive  at  fine  diagnostic  distinctions  con- 
cerning the  reactions  secured  by  differential  function  tests. 
Even  in  the  simplest  clinical  type  of  nephritis  there  is 
enough  general  structural  alteration  to  render  conclu- 
sions   as    to    special    functional    involvement    hazardous. 


308  BLOOD-PRESSURE 

Therefore  as  the  matter  stands,  the  only  methods  available 
for  clinical  usage  are  such  as  furnish  information  as  to  the 
total  function  of  the  kidneys,  i.e.,  their  excretory  capacity. 

The  original  deductions  of  Roundtree  and  Geraghty, 
which  have  been  fully  corroborated  by  subsequent  ob- 
ververs,  show  that  the  amount  of  phthalein  excreted 
varies,  as  a  general  rule,  with  the  extent  of  renal  damage. 

The  test  is  also  valuable  in  cardiorenal  cases  with 
failing  heart  and  kidney  engorgement.  Such  a  condition 
is  accompanied  by  a  low  phthalein  output,  which  rapidly 
rises  as  the  heart's  action  improves,  so  that  this  change 
in  such  a  case  may  be  the  earliest  sign  of  restoration  of 
compensation,  when  it  becomes  of  considerable  prognostic 
importance.  On  the  other  hand,  a  persistently  low 
excretory  capacity  with  apparent  clinical  evidence  of 
cardiac  improvement  points  to  a  severe  nephritis  and  to 
a  less  favorable  prognosis. 

Efforts  to  explain  the  relation  of  the  phthalein  test,  as 
seen  in  practice,  to  the  anatomic  conditions  revealed  in  the 
kidney  in  necropsy  have  been  made  by  many,  including 
Thayer  and  Snowden.^  Their  cases  show  that  in  severe 
chronic  nephritis  there  occurs  most  uniformly  an  unusually 
low  phthalein  output,  which  as  a  rule,  unless  interrupted 
by  an  acute  terminal  process,  decreases  steadily  up  to 
the  onset  of  uremia,  and  that  excretion  may  be  nearly  or 
wholly  suppressed  for  from  only  a  day  or  two  to  a  month 
before  death.  These  authors  state  that  not  in  all  their 
studies  for  five  years  have  they  met  with  a  good  phthalein 
excretion  in  a  case  of  chronic  nephritis. 

There  seems  to  be  no  question  as  to  the  usefulness  of  this 

1  Am.  Jour.  Med.  Set.,  1914,  cxviii,  781. 


NEPHRITIC   HYPERTENSION    AND    CHRONIC    NEPHRITIS        309 

test,  which  when  periodically  employed  constitutes  a 
method  of  value  in  nephritic  and  high-pressure  states 
generally.  It  has  been  observed  that  the  response  to  the 
test  is  on  an  average  higher  in  ambulatory  than  in  hospital 
cases,  irrespective  of  the  clinical  condition  present. 

It  was  first  suggested  by  Miller  and  Cabot  and  has  been 
more  or  less  confirmed  since,  that  the  excretion  of  the 
phthalein  grows  progressively  less  with  advancing  years, 
irrespective  of  the  kidney  condition. 

It  is  a  common  experience  to  note  that  the  output  is 
well  within  the  requirements  in  the  majority  of  cases 
grouped  as  nephritis,  when  accompanied  by  good  cardiac 
compensation,  so  that  while  these  observations  therefore 
may  not  be  of  great  value  in  diagnosis,  they  are  of  un- 
doubted service  in  the  study  of  nephritis,  where  they  may 
often  furnish  the  much-needed  clue  to  the  presence  of 
doubtful  and  unsuspected  uremic  conditions.  The  phtha- 
lein test  is  also  of  value  in  separating  the  cardiorenal  from 
the  cardiovascular  cases.  Finally  from  the  prognostic 
standpoint  the  test  offers  us  great  assistance  when  employed 
periodically. 

The  general  consensus  of  opinion  now  bears  out  the 
original  conclusions  of  Folin,  Dennis  and  Seymour  regard- 
ing this  test  in  relation  to  the  nonprotein  nitrogen  of  the 
blood,  namely,  that  cumulative  phenomena  occur  only  when 
excretion  of  phthalein  falls  below  40  per  cent,  in  the  first 
two  hours. 

(g)  Eye-ground  Examination. — Ocular  symptoms  are 
often  among  the  very  earliest  signs  which  are  susceptible 
of  detection  by  careful  examination,  although  in  some 
cases  these  changes  may  be  greatly  delayed.     This  fact 


310  BLOOD-PRESSURE 

becomes  important,  therefore,  from  a  prognostic  stand- 
point because  the  earUer  the  diagnosis  can  be  made  the 
more  probable  is  it  that  good  results  will  be  secured  from 
treatment. 

Of  recent  years  the  relation  of  retinal  changes  to  blood- 
pressure  and  chronic  kidney  disease  has  attracted  wide- 
spread interest.  As  such  examinations,  occurring  in  the 
course  of  routine  examinations  of  the  eye,  have  often  been 
the  first  clue  to  the  presence  of  chronic  renal  changes  and 
should  therefore  indicate  the  immediate  use  of  the  sphygmo- 
manometer, so  also  should  high  blood-pressure  readings 
call  for  an  ophthalmoscopic  examination.     (See  Fig.  55.) 

PROGNOSIS 

Except  in  the  later  stages,  when  all  signs  point  to  the 
approach  of  death,  a  prognosis  cannot  be  accurately  given 
until  careful  observation  has  extended  over  a  period  of 
time  sufficiently  long  to  permit  the  physician  opportunity 
to  carefully  weigh  the  many  factors  in  the  case  which  must, 
of  necessity,  contribute  to  his  opinion. 

Generally  speaking,  the  earUer  the  diagnosis  the  better 
the  prognosis,  although  there  are  exceptions  to  this.  The 
average  blood-pressure  level  is  a  factor  of  first  importance. 

From  the  standpoint  of  nephritic  involvement  as  bear- 
ing on  the  ultimate  outcome,  the  prognosis  in  the  case  of  a 
robust  looking  man  of  fifty  or  fifty-five,  with  an  average 
blood-pressure  of  200  or  over,  even  with  no  direct  evidence 
of  arteriosclerosis,  is  not  so  good  as  in  the  case  of  a  man 
sixty-five  or  so,  with  marked  evidence  of  arterial  involve- 
ment, who  is  carrying  a  pressure  of  between  130  and  160. 
The  former  is  in  daily  danger  of  a  sudden  total  catastrophe, 


NEPHRITIC    HYPERTENSION   AND    CHRONIC    NEPHRITIS        311 


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Fig.  61. — Female.  Aged  fifty-one.  Uremic  paralysis.  First  observa- 
tion was  made  twenty-four  hours  after  an  attack  of  left  hemiplegia  of  uremic 
origin.  The  urine  showed  albumin  and  hyaline  casts  in  practically  all  speci- 
mens throughout  this  period  of  observation,  although  less  in  amount  in  the 
later  ones.  Elimination  and  sedative  treatment  produced  prompt  reduction 
in  systolic  pressure  to  a  surprising  degree,  followed  by  a  less  marked  fall  in 
pulse  pressure.  At  {A)  the  patient  has  so  far  recovered  the  use  of  her  lower 
extremity  as  to  be  able  to  get  around  with  help.  The  rise  at  this  point  was 
probably  due  to  increased  muscular  activity  and  did  not  give  any  great 
concern.  At  (B)  the  patient  had  an  attack  of  tachycardia  from  no  apparent 
cause,  the  nurse  reporting  that  prior  to  my  examination  the  pulse  was 
almost  imperceptible,  being  over  200  and  uncountable.  Absolute  rest  plus 
morphin  and  ice  bags  resulted  in  a  prompt  fall  in  systolic  pressure. 
Subsequently  the  course  of  the  case  was  uneventful,  the  slight  rise  in 
systolic  and  pulse  pressure  being  due  to  gradually  increasing  physical 
activity. 


312 


BLOOD-PRESSURE 


while  the  latter  may  live  on  for  years  with  apparent  good 
health. 

The  most  that  can  be  expected  from  rational  treatment 
is  a  more  or  less  complete  arrest  of  the  progress  of  the 
disease,  which  can  be  counted  upon  to  delay  the  fatal 
termination  for  a  variable  period,  often  for  years. 

The  result  of  clinical  observations  and  the  persistence 
of  certain  characteristic  changes  seen  at  post-mortem 
examination  indicate  that  one  may,  in  a  certain  number 
of  cases,  forecast  the  ultimate  termination  at  least  in  so  far 
as  the  forecasting  of  the  variety  of  death  is  concerned. 

Janeway^  has  reported  his  findings  in  a  long  series  of 
cases,  from  which  the  following  has  been  largely  taken. 

In  Janeway's  series  twelve  out  of  twenty-nine  cases 
which  died  of  cardiac  insufficiency,  began  with  dyspnea 
on  exertion.  On  the  other  hand,  out  of  thirty-two  patients, 
who  noted  polyuria  or  nocturnal  urination  at  the  beginning 
of  their  illness,  seventeen  died  of  chronic  and  seven  of 
acute  uremia  while  only  eight  died  of  cardiac  insufiiciency. 

Duration  of  Illness  in  Relation  to  Causes  of  Death  (Janeway) 


Cases 

Duration 

Causes  of  death 

Average 

Longest, 
yrs. 

Shortest 

Yrs. 

Mos. 

Yrs. 

Mos. 

Cardiac  insuflaciency .... 
Acute  uremia 

26 
14 
21 
14 
3 
4 

3 
3 

3 

4 
4 
3 

10 

1 
6 
3 

10 

8 
7 
11 
6 
4 

3 

1 

4 
5 

Chronic  uremia 

4 

Cerebral  apoplexj- 

Angina  pectoris 

11 
6 

Acute  edema  of  lungs .... 

8 

*  Loc.  cit. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC    NEPHRITIS       313 

The  relation  of  headache  and  subsequent  uremia  is  most 
striking.  Of  fifteen  patients  complaining  of  headache, 
eight  died  of  chronic  uremia  (Fig.  61),  two  of  apoplexy, 
and  only  one  of  heart  failure. 

Early  ocular  symptoms  were  most  frequent  in  those  who 
died  of  chronic  uremia,  in  five  out  of  eight.  Early  hemo- 
plegic  attacks  occurred  thirteen  times  in  four  patients  who 
finally  died  of  apoplexy. 

SUMMARY 

1.  Early  dyspnea  of  either  type  in  a  patient  with  high 
pressure  indicates  marked  danger  of  cardiac  insufficiency. 
In  such  patients  the  disease  should  be  treated  as  a  cardiac 
disease. 

2.  Anginoid  pain,  even  when  of  marked  severity,  occurring 
in  persons  with  high  blood-pressure,  does  not  make  the 
prognosis  worse  than  other  cardiac  symptoms.  The 
majority  of  these  patients  will  not  die  of  angina. 


The  Relation  of  Prominent  Early  Symptoms  with  High  Blood-pressure  to 
Causes  of  Death  {Janeway) 


Symptoms 

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Causes  of  death 

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Gradual  cardiac  insuflBciency 

29 

7 

2 

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3 

3 

Uremic  convulsions  or  sudden  coma 

15 

5 

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11 

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5 

4 

5 

1 

Gradual  uremia 

20 

6 

2 

0 

2 

2 

2 

2 

1 

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0 

4 

Cerebral  apoplexy  or  its  results 

14 

1 

1 

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2 

0 

0 

0 

0 

0 

0 

0 

Angina  pectoris 

3 

2 

2 

1 

1 

1 

1 

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0 

0 

1 

1 

Edema  of  the  lungs 

4 

3 

3 

0 

1 

1 

3 

2 

0 

1 

3 

6 

Other  causes 

15 

48 

24 

4 

15 

11 

32 

15 

8 

13 

14 

16 

100 

314  BLOOD-PRESSURE 

3.  Polyuria,  nocturnal  frequency,  marked  headache,  or 
visual  disturbances  in  a  patient  with  high  blood-pressure, 
especially  if  the  patient  is  below  fifty  years,  should  make 
the  prognosis  very  guarded,  for  uremia  is  a  frequent  mode 
of  termination  of  these  cases. 

TREATMENT 

From  the  first  inception  until  the  very  end,  the  treatment 
of  chronic  high  pressure  and  chronic  nephritis  should  be  of 
the  individual  and  not  of  the  disease.  This  important  fact 
cannot  be  too  frequently  or  too  positively  repeated  because 
there  is  still  a  large  number  of  practitioners  who  are  en- 
deavoring to  treat  solely  the  kidney  condition  or  one  or  more 
of  the  many  symptoms  or  secondary  complications  with 
which  all  are  familiar.  One  should  never  forget  the  fact 
that  nothing  can  be  done  to  remove  the  existing  degenera- 
tions, while  much  can  and  should  be  done  toward  relieving 
undue  strain  where  such  is  found  to  exist,  by  promoting 
elimination,  favoring  cardiac  action  and  in  general,  regulat- 
ing the  patient's  mode  of  life,  in  an  endeavor  to  readjust 
it  to  existing  conditions.  Any  other  method  may  not  only 
be  useless  but  may  actually  work  harm. 

It  is  absurd  to  treat  any  case  directly  for  the  blood-pres- 
sure elevation,  by  measures  directed  toward  actively  re- 
ducing the  high  pressure,  as  it  has  been  shown  by  many, 
that  in  point  of  longevity^  but  little  difference  is  found 
between  those  whose  systolic  pressure  rises  above  200  and 
those  that  range  between  this  and  150. 

Everyone  should  be  fully  prepared  to  accept  the  state- 
ment that  very  high  blood-pressure  may  exist  as  a  direct 

^  T.  C.  Janeway,  Arch.  Int.  Med.,  xii,  No.  6,  p.  755. 


NEPHRITIC    HYPERTENSION    AND    CHRONIC   NEPHRITIS        315 

response  to  physiologic  stimuli,  and  that  such  a  reaction 
may  be  entirely  natural,  if  not  essential.  Here  it  becomes 
physiologic. 

It  may  be  said,  I  think  without  question,  that  the  most 
important  item  in  the  treatment  of  chronic  nephritis  is  the 
preservation  of  cardiac  compensation.  Neither  is  there  any 
question  but  that  the  elevation  in  systolic  pressure  while 
bearing  a  direct  casual  relation  to  the  cardiac  hypertrophy, 
also  operates  in  conjunction  with  it  in  forming  a  compen- 
satory mechanism  which  alone  is  able  to  maintain  an 
adequate  kidney  function.  They  are,  consequently,  es- 
sential to  the  preservation  of  life,  and  should  be  protected 
by  every  hygienic  and  dietetic  safeguard. 

In  connection  with  treatment  by  hygienic  and  dietetic 
measures,  it  is  often  most  strikingly  demonstrated  that  such 
measures,  if  they  result  in  relief  of  distressing  symptoms, 
cause  a  reduction  in  pulse  pressure  and  that  this  occurs 
even  when  the  systolic  level  is  not  materially  affected. 
In  my  own  work  I  have  come  to  look  upon  this  alteration 
as  auguring  good,  even  when,  as  already  mentioned,  the 
systolic  level  remains  the  same  (see  Fig.  62). 

I  cannot  agree  with  those  authorities  who  divide  the 
treatment  of  this  condition  into  (a)  correction  of  the  tension 
and  (6)  the  administration  of  specific  drugs.  It  is  rare 
except  in  emergency  that  such  drugs  are  required  (as  to 
relieve  threatened  death  from  pulmonary  edema,  acute 
dilatation  of  the  heart  or  apoplexy)  and  they  may  and 
frequently  do  cause  harm.  Therefore,  nitrites  should  be 
reserved  for  emergency  and  then  given  only  when  carefully 
checked  by  the  clinician.  Even  then  they  are  often  of 
little  value  because  of  the  uncertainty  of  their  action. 


316  BLOOD-PRESSURE 

The  appearance  of  dropsy  in  chronic  nephritis  with  high 
pressure  almost  invariably  presages  cardiac  failure.  At 
this  stage  the  digitalis  bodies  become  our  sheet  anchor  of 
treatment.  They  should  not  be  withheld  because  the  blood- 
pressure  is  high,  as  they  have  been  found  to  act  just  as  well, 
or  even  better,  in  the  presence  of  high  pressure  than  with  a 
decreased  pressure.^ 

That  the  ingestion  of  sodium  chloride  favors  fluid  reten- 
tion is  well  known,  so  that  its  reduction  should  be  en- 
couraged, in  any  case  where  the  presence  of  edema  fails  to 
respond  to  other  methods,  although  I  am  not  yet  willing 
to  state  that  salt  restriction  should  be  included  among  the 
dietetic  measures  in  every  case. 

Space  will  not  permit  of  an  extended  discussion  of  the 
many  dietetic,  hygienic  and  therapeutic  measures  which 
may  be  employed  in  the  management  of  the  disease.  Those 
desiring  specific  information  relative  to  the  variety  and  to 
the  effect  of  such  measures  will  find  them  briefly  discussed 
in  Chapters  XXIII  and  XXIV. 

1  A.  R.  Elliott,  Jour.  A.  M.  A.,  Nov.  21,  1914,  Ixiii,  21,  1878. 


CHAPTER  XIX 

CARDIAC  DISEASE:  MYOCARDIAL,  VALVULAR,  AND 
FUNCTIONAL.     MYOCARDIAL  INSUFFICIENCY 

Significance  of  Term. — From  a  practical  standpoint  it 
would  seem  advisable  to  employ  the  general  term  myo- 
cardial insufficiency,  to  the  exclusion  of  all  others,  when 
discussing  from  a  clinical  standpoint  the  pathologic  changes 
which  may  occur  in  the  heart  muscle;  for,  while  we  recog- 
nize pathologically  a  sharp  line  of  demarcation  between 
acute  and  chronic  inflammation,  and  between  fatty  degen- 
eration, fibroid  degeneration  or  fibrosis,  senile  heart  and 
chronic  cardiac  insufficiency,  in  the  majority  of  cases 
there  is  no  way  by  which  these  various  conditions  can  be 
distinguished  from  each  other  cHnically.  Any  attempt 
to  separate  the  various  forms  of  myocardial  change,  by 
a  clinical  study  of  the  case,  is  merely  an  exhibition  of 
ignorance,  for  the  symptoms  supposed  to  indicate  different 
forms  of  myocardial  disease  may  be  caused  by  the  same 
pathologic  conditions.  Also  various  pathologic  changes 
may  give  rise  to  identical  trains  of  symptoms,  so  that  all 
efforts  to  clinically  classify  them  must  necessarily  fail. 

Chronic  myocarditis  causes  weakness  in  the  cardiac 
power,  irrespective  of  the  cause  of  the  pathologic  change 
in  the  heart  muscle.  This  is  evidenced  clinically  by  an 
inadequacy  of  the  circulation  either  during  rest  or  following 
a  demand  for  increased  power. 

317 


318 


BLOOD-PRESSURE 


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Fig.  62. — Male.  Aged  sixty.  Retired  stock  broker.  Cardiovascular- 
renal  disease.  Myocardium  in  fair  condition,  arteries  moderately  rigid. 
The  height  of  systolic  pressure  and  large  pulse  pressure  are  characteristic 
of  arterial  rigidity  and  cardiac  overaction.  The  remissions  are  unexplained 
except  on  the  grounds  of  varying  excitement  and  activity.  Measures 
directed  toward  relief  of  high  pressure  very  unsuccessful,  although  relief 
from  dyspnea,  insomnia  and  early  morning  headache  was  quite  marked, 
and  has  continued  in  spite  of  the  gradual  average  rise  in  systolic  and  pulse 
pressures.  (A)  Large  doses  of  tincture  of  aconite  failed  to  reduce  pressure. 
(B)  An  attack  of  acute  rhinitis  occurred.  (C)  General  condition  good. 
Has  spent  summer  at  seashore  resort.  {D  to  E)  Not  under  any  treatment. 
Absence  of  all  unpleasant  symptoms  and  general  condition  excellent.  Note 
the  stationary  pulse  pressure  in  spite  of  moderate  variations  in  both 
systolic  and  diastolic.  (F)  Attack  of  grippe.  Confined  to  bed  until 
1-16-'16.  Attack  rather  severe  with  marked  toxemia  and  prostration. 
Note  effect  of  treatment  and  rest  upon  systolic,  diastolic  and  pulss 
pressures.  (G)  Note  sharp  rise  in  systolic  as  result  of  extraordinary  exertion 
following  severe  infection,  accompanied  by  dizziness,  insomnia  and  cough. 
Subsequent  treatment  directed  toward  circulation  including  the  use  of 
strychnin  and  caffein  by  mouth. 


CARDIAC    DISEASE  319 

Etiology. — Chronic  myocardial  insufficiency  is  a  condi- 
tion of  the  heart  muscle  resulting  usually  from  some  dis- 
turbance in  nutrition  of  the  heart  muscle.  Leslie  Thorne^ 
says  that  two  of  the  most  common  forms  of  muscle  degen- 
eration resulting  from  hypertension  are  atheroma  and  fatty 
degeneration. 

The  modus  operandi  of  degeneration  is  probably  that 
of  a  disturbed  blood-supply  to  the  heart  itself,  due  to  a 
narrowing  of  the  coronary  arteries.  It  is  therefore  essen- 
tially a  chronic  progressive  process  and,  from  the  intrinsic 
nature  of  the  change,  when  once  the  process  has  become 
fairly  well  started  it  is  but  slightly  amenable  to  treatment. 

Bruce ^  dwells  upon  the  frequency  of  cardiac  degeneration, 
associated  with  glycosuria,  and  also  the  frequent  relation 
of  gout  to  chronic  myocarditis. 

A  most  important  factor,  never  to  be  forgotten  in  this 
strenous  age,  is  the  effect  of  the  constant  strain  of  responsi- 
bility upon  business  men,  legislators,  professional  men, 
etc.,  where  we  find  the  development  of  high  pressure  par- 
ticularly common,  resulting  in  cardiac  enlargement,  with 
more  or  less  insufficiency,  all  of  which  denote  the  beginning 
of  the  end,  unless  the  overstress  be  reduced. 

Belonging  to  the  same  class  of  cases  are  those  due  to 
indiscretions  in  diet  and  sedentary  habits  with  insufficient 
exercise.  Here  the  intra-abdominal  vessels  are  subjected  to 
abnormal  and  prolonged  strain,  which  leads  in  time  to 
sclerosis  of  their  coats,  to  increased  blood-pressure,  cardiac 
overwork  and  eventually  to  degeneration  of  the  myocar- 
dium (see  Fig.  62). 

^Lancet,  June  4,  1910. 
'^Lancet,  July  15,  1911. 


320 


BLOOD-PRESSURE 


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Fia.  63. — Female.  Aged  seventy-three.  Chronic  uremia  and  myocar- 
ditis. Observations  from  (A)  to  {B)  were  made  in  the  course  of  routine  ex- 
amination, following  a  slight  injury.  It  was  noted  that  the  patient's 
mental  condition  was  becoming  clouded  and  her  reflexes  were  exaggerated,  she 
complained  of  being  smothered  and  dizzy  with  persistent  ringing  in  the  ears. 
The  observation  at  (C)  was  made  during  a  mild  attack  of  uremic  coma  with- 
out convulsions,  which  was  relieved  by  the  usual  eliminative  treatment. 
At  (D)  the  kidney  excretion  was  reduced  to  under  15  ounces  in  twenty-four 
hours  and  was  highly  albuminous.  This  state  gradually  responded  to 
digitalis  medication.  At  (F)  the  uremic  condition  had  largely  disappeared 
and  was  replaced  by  dilated  and  incompetent  heart.  The  blood-pressure 
and  an  examination  of  the  circulation  at  this  time  showed  a  rather  character- 
istic evidence  of  heart  muscle  weakness,  in  that  it  was  easy  to  distinguish 


CARDIAC    DISEASE  321 

Fatty  degeneration  of  the  heart  is  due  in  most  cases  to 
the  same  conditions  which  cause  atheroma  of  the  aorta 
and  disturbance  in  the  coronary  circulation. '  It  is  also 
one  of  the  natural  results  of  advancing  age,  where  it  is 
generally  dependent  upon  the  long-continued  action  of 
such  irritations  as  chronic  auto-intoxications,  habitual  use 
of  alcohol,  toxic  effects  of  tobacco,  coffee,  etc. 

Chronic  disease  of  the  kidneys,  by  increasing  the  resist- 
ance' in  the  arterioles  raises  blood-pressure;  this  in  turn  pro- 
duces general  arteriosclerosis,  from  which  the  coronary 
arteries  are  not  exempt,  lead  inevitably  to  myocardial 
degeneration  (see  Fig.  63).  Less  commonly  we  find  fatty 
degeneration  following  protracted  wasting  diseases,  exhaust- 
ing discharges  or  anemia  from  repeated  losses  of  blood. 
Acute  fatty  degeneration  usually  results  from  the  toxins  of 
diphtheria  and  other  acute  infectious  processes,  and  oc- 
casionally from  phosphorous  or  mercurial  poisoning. 

From  the  clinical  standpoint  one  need  not  consider  any 
other  phase  of  the  subject,  as  the  insufficiency  is  largely  a 
mechanical  condition  and  its  effects  are  shown  chiefly  in 
disturbances  of  a  dynamic  nature,  presenting  diminished 
cardiac  energy  on  the  one  hand  and  increased  demand  for 
energy  on   the  other.     In  considering  this  condition  we 

two  apparent  systolic  readings,  i.e.,  the  first  tone  while  distinctly  audible, 
almost  immediately  disappeared,  and  was  then  replaced  by  a  false  first  tone 
as  shown  at  the  apex  of  the  dotted  line  (E) .  This  was  actually  the  beginning 
of  the  third  phase  and  was  caused  by  an  absence  of  the  second  phase.  The 
same  condition  occurred  at  (F),  ((?)  and  {H)  and  these  changes  were  always 
coincident  with  extreme  weakness,  cardiac  arhythmia,  orthopnea  and  pul- 
monary edema,  and  at  the  same  time  the  kidney  excretion  in  twenty-four 
hours  was  variously  recorded  at  from  10  to  16  ounces.  At  the  last  examina- 
tion the  patient  showed  more  the  effect  of  myocardial  than  a  renal  involve- 
ment, as  shown  by  weakness  in  the  second  and  third  auscultatory  sounds 
and  the  tendency  to  a  slight  average  reduction  in  systolic  pressure  together 
with  a  slight  rise  in  the  average  pulse  pressure. 


322 


BLOOD-PRESSURE 


Fig.  64. — Female.  Aged  fifty-five.  Apparent  age  sixty-five.  Chronic 
myocarditis  and  autotoxemia.  Has  long  been  a  sufi'erer  from  the  effects 
of  extensive  pelvic  inflammation  and  has  had  several  operations.  Consulta- 
tion on  account  of  symptoms  suggestive  of  gout,  developed  evidence  of 
cyanosis,  dyspnea  and  cough.  Examination  of  the  urine  showed  low 
specific  gravity,  traces  of  albumin,  granular  and  hyaline  casts  and  red 
blood  cells.  The  blood-pressure  was  210  mm.  Hg.  The  arteries  were 
moderately  fibrous,  the  heart  muscle  sounds  were  poor  and  there  is  a  faint 
systolic  murmur  over  the  body  of  the  heart.  Hygienic  measures  and  warm 
baths  were  instituted.  The  effect  of  these  measures  on  blood-pressure  (A 
to  B)  seemed  to  justify  the  assumption  of  a  large  autotoxemia  element. 
Return  to  ordinary  habits,  which  have  always  been  active,  probably  ac- 
counted for  the  rise  at  (C)  although  the  patient  was  at  this  time  symptom- 
free.  At  (D)  the  patient  complained  of  dyspnea  on  exertion,  a  feeling  of 
fullness  in  the  chest,  and  tingling  and  weakness  in  left  arm,  which  were 


CARDIAC    DISEASE  323 

cannot  confine  ourselves  strictly  to  a  study  of  these  hearts 
which  are  doing  less  than  the  average  amount  of  work,  as 
such  hearts  may  actually  be  over-exerting  themselves,  but 
handicapped  by  leaky  valves  or  high  arterial  pressure, 
they  Sire  forced  into  this  class.  We  must  make  a  distinction 
between  inefficiency  and  insufficiency.  Hearts  may  be 
insufficient  because  they  have  a  lessened  reserve  and  ineffi- 
cient because  they  have  an  excessive  amount  of  work  to 
perform. 

Definition. — Myocardial  insufficiency  (Fig.  64)  may  be 
described  as  the  condition  when  a  heart  with  normal  valves 
does  not  possess  sufficient  power  to  drive  the  required 
amount  of  blood  with  the  normal  velocity  through  a  normal 
arterial  system.*  This  is  a  positive  intrinsic  vital  defect. 
It  also  exists  when  valvular  disease  imposes  a  burden  of 
leakage  greater  than  the  heart  is  able  to  compensate  and 
when  high  arterial  pressure  demands  additional  energy  to 
maintain  circulatory  equilibrium.  Under  these  conditions 
the  insufficiency  is  relative,  mechanical  or  extrinsic. 

Such  a  clear-cut,  positive  distinction  can  seldom  be  made 
in  practice,  as  sooner  or  later  all  cases  will  be  found  to 
participate  in  both. 

Myocardial  Sufficiency. — According  to  Gifford^  the 
normal  heart  of  a  normal  individual  under  thirty  years  of 


relieved  by  rest  and  hot  packs.  At  (E)  the  symptoms  returned  and 
dyspnea  became  more  marked.  At  (F)  general  condition  good  in  the  absence 
of  special  measures.  There  is  nothing  further  important  in  subsequent 
history.  Beneficial  effect  of  treatment  shown  by  slightly  lowered  general 
average  pulse  pressure  which  should,  under  proper  management,  be  main- 
tained for  an  indefinite  period. 

1  U.  G.  Gifford,  Penna.  Med.  Jour.,  September,  1915,  xviii,  12,  p.  913. 

2  Loc.  cit. 


324  BLOOD-PRESSURE 

age  with  the  body  at  rest,  does  not  expend  more  than 
one-twelfth  of  its  potential  or  reserve  energy.  At  moderate 
work  one-foui*th  to  one-third  is  used,  while  the  full  capacity 
is  demanded  only  in  the  most  severe  forms  of  exercise 
demanding  great  endurance.  With  the  body  at  rest  60 
c.c.  of  blood  is  expelled  at  each  systole,  at  the  rate  of  seventy- 
two  times  per  minute.  Additional  demands,  the  result  of 
exercise,  can,  according  to  Plesch,  drive  the  heart  to  deliver 
six  times  this  volume  in  the  same  interval  of  time.  This 
is  the  factor  of  safety,  encroachment  upon  this  and  reduc- 
tion in  it  being  the  most  characteristic  features  of  myo- 
cardial insufficiency,  and  in  proportion  to  this  encroach- 
ment is  the  myocardium  found  insufficient. 

Varieties  of  Insufficiency. — In  the  intrinsic  vital  form  of 
myocardial  insufficiency  the  cardiac  muscle  has  less  than 
normal  power  to  respond  to  the  inci^eased  demands,  while 
in  the  extrinsic  mechanical  form  (valvular  disease  and  high 
arterial  pressure)  the  heart  is  handicapped  by  the  load  it 
carries,  and  in  both  classes  the  factor  of  safety  is  reduced  in 
proportion  to  the  severity  of  the  existing  conditions. 

Secondary  Factors  Contributing  to  Incompetency. — The 
heart  under  the  above  conditions  cannot  at  any  time  or 
under  any  circumstances  respond  to  the  demand  for  ad- 
ditional effort,  neither  can  it  get  the  normal  amount  of 
reUef  that  bodily  rest  should  afford.  The  inevitable  and 
unfailing  result  of  these  changes  is  impairment  of  myo- 
cardial nutrition,  while  in  addition  it  also  suffers  from 
insufficient  coronary  circulation,  which  is  the  result  of 
an  improper  oxygen  content  of  the  blood  supplied  to  the 
heart  and  abnormal  function  of  this  blood,  due  to  excess 
of  products  of  waste  and  fatigue  toxins. 


CARDIAC    DISEASE  325 

Effect  of  Strain  upon  Insufficient  Hearts. — While  a 
strong  heart  tends  to  decrease  in  size  during  exercise, 
the  weakened  heart  tends  to  increase,  or  in  other  words  to 
dilate.  This  is  due  to  a  deficiency  in  tonus;  consequently 
a  heart  in  which  the  muscle  is  diseased  will  dilate  upon 
comparatively  slight  exertion.  In  cardiac  degeneration 
there  is  always  diminished  tonicity,  therefore  diminished 
tonus  is  an  important  factor  in  the  production  of  per- 
manent dilatation. 

In  this  connection  the  venous  pressure  plays  an  impor- 
tant part,  as  venous  pressure  is  increased  by  exercise, 
and  is  particularly  high  during  straining,  heavy  hfting, 
etc.,  this  is  frequently  a  factor  in  the  production  of  over- 
strain, because  a  high  venous  pressure  keeps  the  right 
ventricle  dilated,  and  if  the  tonicity  is  low,  the  heart  muscle 
will  remain  dilated.  According  to  the  researches  of 
Louis  M.  Warfield^  the  most  important  factor  in  the 
production  of  chronic  dilatation  is  constant  repetition 
of  the  strain.  Even  a  mildly  diseased  heart  may  recover 
from  considerable  strain,  provided  the  strain  ceases  quickly 
or  if  time  is  allowed  for  the  heart  to  return  to  normal  size 
before  the  second  strain  occurs.  On  the  other  hand, 
if  repeated  strain  occurs  to  a  heart  already  dilated,  having 
low  tonicity,  then  permanent  damage  results.  The  border 
line  between  true  heart  failure  and  complete  recovery 
depends  to  a  large  degree  upon  the  period  of  rest  after 
strain. 

Heart  Failure. — Broken  compensation  does  not  occur  in 
a  normal  heart,  however  severe  the  exercise  may  be.  A 
normal  heart  muscle  is,   however,   capable  of  becoming 

^Interstate  Med.  Jour.,  p.  994,  1911. 


326  BLOOD-PRESSURE 

acutely  dilated.  In  this  condition  the  pulse  may  be  so 
rapid  that  it  cannot  be  counted,  and  nausea  and  vomiting 
may  occur.  In  sudden  heart  failure  the  blood-pressure 
falls  rapidly;  I  have  seen  the  systolic  pressure  drop  30  to 
40  mm.,  and  the  diastolic  20  to  25  mm.,  in  less  than  three 
minutes.  The  patient  may  faint  from  the  exertion,  but 
so  far  as  we  know,  such  hearts  return  after  a  time  to  normal 
size  and  by  virtue  of  the  normal  tonicity  of  the  heart 
muscle  no  permanent  damage  results.  Even  hearts  with 
evident  valvular  lesions  do  not  break  down,  except  tem- 
porarily, unless  the  ventricle  is  diseased.  The  usual 
symptoms  of  heart  failure  occur  often  without  warning, 
when  the  patient  is  seized  with  sharp  precordial  pain  ac- 
companied by  faintness  and  dizziness,  following  which  he 
may  sink  back  in  his  chair  or  fall  to  the  floor  and  expire 
before  any  assistance  can  be  rendered. 

Symptomatology  of  Chronic  Myocardial  Insufficiency. — 
One  of  the  earliest  manifestations  of  myocardial  change  is 
the  development  of  peculiarities  in  rhythm.  Careful 
investigation  will  often  show  that  the  function  of  rhyth- 
micity  has  been  interfered  with,  causing  intermittence, 
irregularity  and  extra  contraction,  or  extra-systoles.  This 
means  damage  to  the  heart  muscle. 

F.  R.  NuUer^  is  of  the  opinion  that  since  we  so  frequently 
find  arteriosclerosis  in  failing  hearts  in  later  years,  in  those 
who  earlier  showed  extra-systoles,  we  should  pay  more 
attention  to  this  symptom,  as  it  probably  represents  a  very 
early  stage  in  the  evolution  of  this  disease. 

In  many  cases  beginning  myocardial  change  may  be 
perceived  by  studying  the  two  aortic  tones,  as  the  first  sound 

1  Harvey  Lecture,  1906-07. 


CARDIAC    DISEASE  327 

in  the  aortic  area  may  be  unchanged,  weakened  or  accom- 
panied by  a  murmur,  while  the  second  sound  may  be  either 
intensified  or  diminished.  A  systoHc  aortic  murmur 
occasionally  may  be  due  to  a  blood  state,  but  in  a  person 
of  middle  age  it  is  strong  evidence  in  favor  of  alterations 
in  the  aortic  wall  and  in  the  myocardium.  Should  these 
findings  be  associated  with  thickened  peripheral  arteries 
and  an  elevated  blood-pressure,  slight  but  persistent,  the 
conclusion  that  myocarditis  is  present  is  warranted, 
especially  when  in  addition  there  have  been  subjective 
signs  of  muscular  weakness.  Where  the  transverse  diame- 
ter of  the  heart  can  be  shown  to  be  increased,  the  diag- 
nosis of  a  cUnically  weakened  and  insufficient  heart  is 
assured. 

Not  infrequently  the  degenerative  process  progresses 
without  symptoms  and  is  not  discovered  until  an  attack 
of  dyspnea  or  fainting  occurs  or  a  paroxysm  of  angina 
pectoris  proves  immediately  fatal. 

As  a  result  of  feeble  circulation  or  of  venous  congestion, 
or  the  development  of  emboli,  many  other  symptoms  and 
signs  may  appear  in  individual  cases  which,  if  the  physician 
is  on  his  guard,  may  readily  be  traced  to  their  true  source. 

Diagnosis  of  Myocardial  Efficiency. — From  the  fore- 
going it  is  evident  that  the  determination  of  the  degree  of 
muscular  efficiency  of  the  heart,  either  simple  or  compli- 
cated with  valvular  defects  and  high  arterial  pressure,  is 
far  from  a  simple  problem,  but  one  which  must  be  attacked 
carefully,  requiring  more  than  average  diagnostic  skill 
and  ingenuity. 

Many  investigators  now  as  in  the  past  are  vigorously 
attacking  this  problem,  studying  the  effects  of  postural 


328  BLOOD-PRESSURE 

changes  and  physical  exercise  on  the  systolic,  diastolic  and 
pulse  pressures,  on  the  pulse  rate,  and  on  venous  pressure. 

A  brief  review  of  the  normal  effects  of  exercise  on  the 
heart  and  circulation  will  serve  to  bring  out  the  important 
diagnostic  features  of  the  so-called  functional  tests. 

Effect  of  Muscular  Work  on  the  Heart. — Regarding  the 
effect  of  muscular  exertion  upon  blood-pressure,  we  believe 
that  in  normal  hearts  there  is  a  rise  in  systolic  pressure 
and  a  less  proportionate  rise  in  diastolic  pressure  with  the 
accompanying  increase  in  pulse  pressure;  and  that  the 
more  habituated  the  individual  is  to  performing  the  work 
(as  in  training)  the  less  the  tendency  for  a  marked  systolic 
rise  to  occur,  as  we  find  that  in  highly  trained  athletes  the 
systolic  pressure  may  fall,  though  the  pulse  pressure  will 
have  increased.  In  the  average  individual  the  primary 
systolic  rise  is  followed  by  a  fall  to  or  below  normal  upon 
the  cessation  of  effort.  The  more  strenuous  the  work,  the 
sharper  the  rise,  but  following  spasmodic  as  opposed  to 
regular  efforts,  the  speedier  and  greater  will  be  the  fall. 
This  depression  in  pressure  after  exercise  has  been  variously 
ascribed  to  fatigue,  to  vasomotor  insufficiency  and  to 
temporary  cardiac  dilatation. 

In  well-compensated  valvular  lesions  and  in  neurotic  hearts 
the  effect  of  exercise  is  the  same  as  in  normal  individuals, 
and  the  average  rise  according  to  Buttermann  is  13  nim., 
whereas  in  myocardial  cases,  instead  of  the  rise  there  occurs 
a  fall  varying  from  3  to  13  mm. 

Effect  of  Postural  Change,  without  Muscular  Exertion 
upon  Arterial  and  Venous  Pressures. — Barach  and  Marks ^ 
summarize  their  findings  in  normal  circulations  as  follows: 

^  J.  H.  Barach  and  W.  L.  Marks,  Arch.  Int.  Med.,  May,  1913,  p.  485. 


CARDIAC    DISEASE  329 

1.  When  the  element  of  muscular  effort  has  been  elimi- 
nated, change  of  bodily  posture  from  the  erect  to  the 
horizontal  will  cause  an  increase  in  the  systolic  pressure, 
a  decrease  in  the  diastolic  pressure  and  an  increase  in  the 
pulse  pressure. 

2.  After  five  minutes  in  the  horizontal  posture,  when  the 
subject  is  returned  to  the  erect  posture,  the  systolic  pres- 
sure will  diminish,  the  diastolic  pressure  will  increase  and 
the  pulse  pressure  will  diminish.  It  will  be  noted  that  in 
both  instances  the  pulse  pressure  follows  the  same  trend 
as  the  systolic  pressure. 

3.  Change  of  posture  from  the  erect  to  horizontal  caused 
a  fall  in  the  venous  pressure. 

4.  Change  of  posture  from  the  horizontal  to  erect  caused 
an  increase  of  the  venous  pressure. 

It  will  be  noted  that  the  venous  pressure  follows  the  same 
trend  as  the  diastolic  pressure. 

Change  from  erect  to  horizontal  causes  in  the  majority 
of  the  cases  a  decrease  of  the  systolic  pressure  and  an 
increase  of  diastolic  pressure. 

General  Summary 

Erect  Horizontal  Erect 

Maximum X                    +  — 

Minimum X                    —  + 

Pulse  pressure X                    +  — 

Venous  pressure X                   —  + 

In  Heart  Cases. — Change  from  the  erect  to  the  hori- 
zontal without  effort  caused  the  systolic  pressure  to  increase 
in  five  cases.  From  the  horizontal  back  to  the  erect  a 
fall  occurred  in  six  and  a  rise  in  two.  The  diastolic,  in 
change  from  the  erect  to  the  horizontal,  fell  in  eight  and 


330 


BLOOD-PRESSURE 


rose  in  one  while  in  the  reverse  the  diastolic  pressure  rose 
in  seven  and  fell  in  one,  while  the  rise  was  to  a  higher 
level  in  five  out  of  eight. 

Relation   of  Pulse  Pressure   to    Venous  Pressure. — The 
tendency  in  the  normal  is  for  a  simultaneous  increase  in 


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both.     In  heart  cases,  irrespective  of  the  lesion,  the  response 
is  similar. 

It  is  well  known  that  a  fall  in  pressure  of  10  mm.  or  more 
in  change  of  posture  from  the  recumbent  to  the  erect  is  a 
sign  of  poor  vasomotor  equilibrium.  But  this  does  not 
indicate  whether  the  defect  is  functional  or  organic. 


CARDIAC    DISEASE  331 

Katzenstein's  Test. — This  test  has  been  employed  to 
determine  the  degree  of  functional  capacity  of  the  heart 
and  is  based  upon  the  reaction  of  this  organ  to  compression 
of  both  iliac  arteries,  as  it  has  been  found  that  in  the 
higher  animals,  including  man  (possessing  normal  hearts), 
such  pressure  causes  a  rise  in  systolic  pressure  of  from  5 
to  15  mm.,  with  a  stationary  or  diminishing  pulse  rate,  if 
the  obstruction  is  maintained  for  several  minutes;  while 
in  diseased  but  hypertrophied  hearts,  with  good  compensa- 
tion, the  blood-pressure  rises  to  40  or  more  millimeters 
while  the  pulse  rate  is  unchanged. 

Graupner's  Test. — This  is  based  upon  the  physiologic 
fact  that  a  given  amount  of  exercise,  such  as  ten  bending 
movements,  or  running  up  a  flight  of  stairs,  causes  both 
an  acceleration  in  the  pulse  rate  and  a  rise  in  blood-pressure, 
but  the  latter  does  not  occur  coincidentally  with  the  former; 
or  if,  as  in  some  cases,  the  pressure  does  rise  first,  it  fails 
to  rise  again  after  the  pulse  has  returned  to  normal.  It  is 
this  secondary  rise  which  indicates  a  good  heart  muscle. 
A  not  too  seriously  affected  heart  may  show  a  rise  in  blood- 
pressure  immediately  after  the  exertion,  but  with  the  slow- 
ing of  the  pulse,  the  pressure  will  be  found  to  have  fallen  to 
a  level  lower  than  before  the  experiment.  The  sphygmo- 
manometer is  required  for  an  accurate  demonstration  of 
these  changes  in  pressure,  which  may  be  recorded  in  definite 
units  of  measure  for  future  reference  and  comparison. 

Shapiro*s  Test. — This  is  based  upon  the  alteration  in 
pulse  rate  occurring  in  normal  individuals  by  change  of 
posture  from  the  standing  to  the  recumbent.  Normally, 
the  number  of  pulse  beats  per  minute  is  from  seven  to  ten 
less  in  the  recumbent  position,   but  when  chronic  myo- 


332 


BLOOD-PRESSURE 


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Fig.  66. — Male.  Aged  twenty-three.  Musician.  Typical  aortic  regur- 
gitation. Transverse  diameter  of  heart  over  8  in.  Characteristic  signs  of 
this  disease  present.  Observations  have  all  been  made  during  period  of 
compensation  and  show  usual  height  of  systolic  pressure.  Characteristic 
extremely  low  diastolic  and  large  pulse  pressure.  (A)  Observation  followed 
a  period  of  dyspnea  with  palpitation  and  subjective  irregularity,  the  result 
of  mental  excitement  due  to  illness  in  family.  (B)  Has  had  another  attack 
of  rheumatoid  pains  throughout  body,  is  short  of  breath,  has  a  poor 
appetite  and  is  constipated.  Heart  is  irregular.  Note  the  change  in  pulse 
pressure  at  this  point,  which  may  in  part  be  accounted  for  by  slight  over- 
exertion and  mental  worry,  although  the  difficulty  in  determining  the  dias- 
tolic point  by  auscultation  in  this  class  of  cases  may  have  contributed. 


CARDIAC    DISEASE  333 

carditis  develops  this  difference  tends  to  disappear,  so  that 
in  seriously  weakened  hearts  the  pulse  may  be  as  rapid  in 
the  recumbent  as  in  the  standing  posture. 

Cautions. — It  is  not  advisable  to  apply  Katzenstein's  or 
Graupner's  tests  to  patients  with  excessively  high  blood- 
pressure,  in  those  of  apoplectic  tendency  or  in  those  with 
high-grade  arteriosclerosis.  The  tests  are  unsafe  in  those 
with  a  systolic  pressiu-e  of  200  mm.  or  over.  In  such  cases 
there  is  danger  of  ocular  or  cerebral  hemorrhage  or  acute 
dilatation  of  heart. 

CHRONIC  VALVULAR  AND  FUNCTIONAL  CARDIAC  DISEASES 

General  Considerations. — From  the  clinical  standpoint 
the  chief  interest  in  all  chronic  valvular  lesions  of  the  heart, 
irrespective  of  the  etiology,  centers  around  the  condition 
of  the  heart  muscle,  i.e.,  functional  efficiency.  A  func- 
tionally efficient  heart  is  sufficient  to  the  needs  of  the  cir- 
culation, so  that  any  treatment  directed  toward  the  heart 
will  be  in  an  effort  to  promote  and  maintain  muscular 
efficiency  or  to  guard  the  insufficient  heart  muscle  from 
overstrain.  While  we  may  be  interested  as  clinicians  in 
the  effect  of  a  particular  valvular  lesion  or  disturbance  in 
the  neuromuscular  mechanism  of  the  heart,  we  are  as 
therapeutists  most  particularly  interested  in  the  myo- 
cardium. In  every  case  the  most  important  question  to 
be  answered  is:  What  is  the  degree  of  muscular  efficiency? 
Insufficiency  is  not  wholly  incident  to  a  valvular  imper- 
fection, but  is  dependent  to  a  great  degree  upon  cardiac 
muscular  efficiency;  that  is,  the  yet  remaining  portion  of 
potential  or  reserve  force  that  may  in  time  of  need  be 
called  out. 


334  BLOOD-PRESSURE 

It  has  already  been  noted  that  a  normal  circulation  pre- 
supposes a  normally  acting  heart,  while  on  the  other  hand, 
abnormality  in  the  heart's  action  is  promptly  manifest  in 
the  circulation,  so  that  in  any  consideration  involving  the 
condition  of  the  heart  we  must  include  a  thorough  and 
comprehensive  study  of  the  circulation,  directing  our  at- 
tention primarily  to  the  state  of  blood-pressure  and  the 
character  of  the  pulse.  It  is  self-evident  that  to  consider 
this  subject  intelligently  one  must  have  a  knowledge  of 
the  normal  blood-pressure  and  its  variations.  We  must 
appreciate  the  significance  of  a  mechanical  hypotension  as 
referred  to  in  detail  on  page  238  and  the  various  forms  of 
hypotension  discussed  on  page  236. 

Blood-pressure  in  Heart  Disease. — Owing  to  the  almost 
unlimited  power  of  the  heart  to  accommodate  itself  to  a 
great  variety  of  external  and  internal  influences,  both  of  a 
temporary  and  of  a  permanent  nature,  such  as  occur  in 
valvular  and  myocardial  diseases,  it  is  surprising  that  blood- 
pressure  observations  often  show  but  small  variations, 
and  it  is  not  uncommon  to  meet  advanced  cases  of  myo- 
cardial and  valvular  disease  in  which  the  alteration  in  the 
systolic  blood-pressure  is  insignificant.  The  conditions 
usually  responsible  for  elevated  pressure  in  chronic  valvular 
disease  are  arteriosclerosis  and  chronic  renal  disease. 
The  one  exception  to  this  is  aortic  regurgitation.  In- 
creased blood-pressure  is  essentially  a  vascular  and  myo- 
cardial and  not  a  valvular  phenomenon.^  It  will  be  seen, 
therefore,  that  in  valvular  lesions  the  actual  blood-pressure 
readings  are  a  reflection  of  existing  secondary  conditions, 
of  a  progressive  nature,  rather  than  of  the  cardiac  lesion 

1  V.  T.  Korke,  Lancet,  Dec.  21,  1911,  clxxxi,  No.  4605. 


CARDIAC    DISEASE  335 

itself.  Korke^  reports  a  large  series  of  observations  made 
(under  carefully  controlled  surroundings)  of  the  respira- 
tion, pulse  rate,  sphygmographic  tracings,  besides  com- 
plete blood-pressure  readings,  from  which  he  concludes 
that  in  chronic  valvular  lesions  of  the  heart  due  to  the  usual 
causes,  the  blood-pressure  is  normal  or  slightly  above, 
whereas  in  aortic  incompetence,  complicated  with  anginal 
attacks,  the  blood-pressure,  contrary  to  the  usual  belief, 
is  often  subnormal  during  the  periods  between  the  attacks 
of  angina. 

In  valvular  lesions  complicated  with  chronic  nephritis 
and  arteriosclerosis  the  significance  of  the  high  pressure 
is  explained  by  the  accompanying  phenomena. 

AORTIC  INSUFFICIENCY 

In  well-compensated  aortic  insufficiency  the  systolic 
blood-pressure  is  usually  found  to  be  somewhat  elevated 
(see  Fig.  66)  ranging  between  130  and  160  mm.  (Korke's 
observations  do  not  agree  with  this.)  Following  the  onset 
of  this  lesion  the  circulatory  efficiency  of  the  heart  is 
probably  maintained  by  reflex  vascular  stimulation  and 
later  by  changes  in  the  myocardium,  as  shown  by  a  great 
left  ventricular  hypertrophy,  so  that  as  long  as  compensa- 
tion is  maintained  the  systolic  pressure  remains  above  the 
average  level.  With  the  advent  of  cardiac  muscle  failure 
it  tends  to  fall,  rising  again  if  the  therapeutic  measures 
employed  prove  effectual. 

In  discussing  the  persistent  arterial  heart  sound  in 
aortic  regurgitation,  which  until  recently  has  been  a 
stumbling   block   in   the   determination   of   the   diastolic 

^Loc.  cit. 


33G  BLOOD-PRESSURE 

pressure,  Taussig  and  Cook^  state  that,  in  spite  of  the  pre- 
vaihng  opinion,  the  persistent  arterial  sound  is  not  pathogno- 
monic of  aortic  regurgitation,  often  being  absent  in  this 
disease  and  occasionally  present  in  others. 

Prognosis. — In  heart  affections,  particularly  valvular, 
a  rapid  and  persistent  reduction  in  systolic  pressure  is 
always  an  unfavorable  sign,  showing  that  the  heart  is 
beginning  to  fail.  The  same  may  be  said  of  a  diminishing 
pulse  pressure,  while  a  slightly  elevated  systolic  pressure 
may  be  looked  upon  with  favor. 

Special  Methods  of  Determining  Aortic  InsuflSciency. — 
Leonard  Hill  has  shown  that  the  blood-pressure  in  the  arm 
as  compared  with  that  in  the  leg  in  normal  individuals,  at 
muscular  rest,  differs  only  by  the  hydrostatic  pressure  of 
the  column  of  blood  which  extends  from  the  leg  to  the 
arm.  In  the  horizontal  posture  they  are  approximately 
equal.  Exercise  in  the  upright  posture  produces  a  much 
wider  variation  in  the  leg  than  in  the  arm,  a  fact  which 
is  attributed  to  the  mechanism  which  regulates  the  pressure 
to  the  heart  itself  and  to  the  vital  centers.  In  patients 
with  aortic  insufficiency  he  has  found  a  constant  greater 
difference  between  the  arm  and  the  leg  readings  even  during 
muscular  quiet  in  the  recumbent  posture,  so  that  he  con- 
siders a  marked  and  constant  excess  in  the  systolic  blood- 
pressure  of  the  lower  extremities  as  compared  with  the 
upper  as  pathognomonic  of  aortic  insufficiency.  Accord- 
ing to  -H.  A.  Hare  this  variation  is  not  present  in  other 
valvular  lesions.  In  normal  individuals  at  rest  it  rarely 
exceeds  15  mm.,  while  with  aortic  insufficiency  it  may 
amount  to  100. 

'  A.  E.  Taussig  and  J.  E.  Cook,  Arch.  Int.  Med.,  May,  1913,  xi,  5. 


CARDIAC   DISEASE 


337 


E.  Pesci^  derives  valuable  information  from  a  study  of 
the  difference  in  systolic  blood-pressure  in  the  brachial 


Fig.  67. — Girl.  Aged  twelve.  Mitral  valvulitis.  Acute  endocarditis 
following  follicular  tonsillitis.  Classical  signs  of  endocarditis  with  a  blowing 
systolic  murmur,  slight  cyanosis,  air  hunger  and  a  greatly  enlarged  and  tender 
liver.  The  rise  in  pulse  pressure  following  the  institution  of  treatment,  was 
probably  the  result  of  return  of  more  blood  to  the  left  side  of  the  heart 
incident  to  the  relief  of  pulmonary  and  hepatic  congestion  following  hot 
packs.  The  gradual  fall  in  systolic  pressure  to  termination  of  the  case  shows 
a  gradual  wearing  out  of  the  heart  caused  by  the  sudden  development  of  a 
demand  for  extra  work.  The  rise  in  pulse  rate  is  characteristic.  The  last 
observation  was  made  shortly  before  death. 

and  digital  arteries  in  heart  disease.     In  aortic  defects  the 


22 


Riforma  Medica,  June  7,  1909,  xxv,  23. 


338 


BLOOD-PRESSURE 


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Fig.  68. — Female.  Aged  fifty-two.  Mitral  regurgitation.  First  obser- 
vation (A)  made  in  period  of  decompensation  in  the  presence  of  anasarca, 
orthopnea,  cyanosis  and  delirium  cordis.  The  case  only  began  to  recover 
muscular  tone  at  {B)  and  then  rapidly  progressed  to  a  state  of  improvement 
which  permitted  moderate  activity  without  untoward  effect.  An  attack  of 
right-sided  dilatation  developed  at  (C),  at  which  time  there  was  present 
little  edema  except  in  the  lungs,  which  were  moderately  filled  with  fluid 
producing  orthopnea,  and  a  continuous  cough  with  frothy  expectoration. 
A  similar  attack  occurred  at  {D),  while  at  {E)  there  was  some  improvement, 
although  the  patient  was  still  confined  to  bed. 


CARDIAC    DISEASE  339 

pressure  in  both  arteries  is  much  higher  than  in  normals, 
whereas  in  associated  myocarditis  the  brachial  pressure 
may  be  high  but  the  peripheral  pressure  is  low.  He  con- 
siders these  observations  especially  instructive  when  the 
brachial  and  digital  pressures  are  determined  before  and 
after  exercise.  If  the  heart  is  functionally  capable,  a 
normal  proportion  of  pressures  between  the  two  readings 
is  maintained.  The  lower  the  peripheral  reading  as  com- 
pared with  the  proximal,  the  weaker  the  myocardium. 

MITRAL  DEFECTS 

In  mitral  defects  (Fig.  67)  and  all  other  compensated 
valvular  lesions,  except  possibly  a  mitral  stenosis,  the 
blood-pressure  is  above  normal.  Starling^  believes  that 
no  matter  how  ill  the  patient  or  how  ineffective  the  work 
of  the  heart,  the  systolic  pressure  is  never  below  normal. 
Pesci^  states  that  in  mitral  defects  during  the  period  of 
compensation  the  pressure  in  both  the  brachial  and  digital 
arteries  is  low,  whereas  it  is  above  normal  when  com- 
pensation fails  (see  Fig.  68). 

Mitral  Stenosis. — The  question  as  to  the  usual  level  of 
systolic  pressure  in  mitral  stenosis  has  not  yet  been  settled. 
In  those  cases  showing  a  subnormal  pressure  it  is  ex- 
plained on  the  ground  that  the  volume  of  blood  actually 
passing  through  the  heart  is  sufficiently  reduced  to  cause 
this  low  pressure.  On  the  other  hand,  the  belief  that  the 
blood-pressure  is  high  in  mitral  stenosis  is  based  upon  the 
fact  that  venous  pressure  is  high  and  the  physics  of  the 
circulation  demand  a  certain  difference  between  the  arterial 

1  Lancet,  Sept.  29,  1907. 

2  Loc.  cit. 


340  BLOOD-PRESSURE 

and  the  venous  pressures.  This  point  has  been  dwelt 
upon  by  Bishop^  who  states  that  failure  of  the  circulation 
in  heart  disease  becomes  a  matter  of  concern  only  when 
the  patient  resumes  his  occupation  and  even  then  a  low 
systolic  pressure  should  not  be  regarded  as  serious  except 
when  it  is  but  little  above  the  venous  pressure. 

CARDIAC  LOAD  AND  OVERLOAD 

Willard  J.  Stone^  has  devised  a  formula  whereby  the 
degree  of  cardiac  load  and  overload  may  be  determined 
and  expressed  in  comparable  figures.  This  study  is  based 
upon  the  assumption  that  clinically  the  pulse  pressure 
represents  the  load  of  the  heart,  which  under  normal  con- 
ditions approximates  50  per  cent,  of  the  diastolic  pressure. 
The  systolic  and  pulse  pressures  represent  myocardial 
values,  while  the  diastolic  pressure  represents  arterial 
resistance  and  is  therefore  the  arterial  factor.  The  founda- 
tion for  this  contention  is  based  upon  a  study  of  sixty-one 
normal  persons  whose  average  pressures  were  systolic  123, 
diastolic  80,  pulse  pressure  40.  The  amount  of  energy 
expanded,  therefore,  to  maintain  the  circulation  in  excess 
of  that  required  to  open  the  aortic  valve,  i.e.,  overcome 
peripheral  resistance  of  80  was  40  (see  also  my  normal 
chart,  page  117).  The  normal  load,  therefore,  may  be 
considered  '^%q  or  50  per  cent,  of  the  diastolic  pressure. 
In  twenty-one  acute  infectious  cases  that  recovered  the 
average  pressure  was  systolic  119,  diastolic  76,  pulse  pres- 
sure 42,  the  load  in  this  case  being  ^^^g  or  55  per  cent. 
On  the  other  hand  in  five  fatal  acute  infections  the  averages 

^  "Heart  Disease  and  Blood-pressure,"  1907. 
^Jour.  A.  M.  A.,  Oct.  4,  1913,  Ixi,  14,  p.  1256. 


CARDIAC    DISEASE  341 

were  systolic  102,  diastolic  68,  pulse  pressure  34,  and  the 
load  ^%s  or  50  per  cent. 

Preceding  circulatory  failure,  there  may  be  a  radical 
change  in  the  readings,  with  a  tendency  for  the  pulse 
pressure  to  equal  or  exceed  the  diastolic.  Thus  in  six 
of  fourteen  decompensated  myocardial  cases  the  pulse 
pressure  approached  or  exceeded  the  diastolic.  From 
this  it  appears  that  with  a  load  factor  of  50  plus  an  overload 
of  50  per  cent,  {i.e.,  when  the  pulse  pressure  equals  the 
diastolic)  there  is  great  danger  of  myocardial  failure. 
Another  condition  enters  here,  which  is  the  commonly 
associated  rapid  heart  rate,  which  Henderson  and  Bar- 
ringer^  have  shown  to  be  a  factor.  A  rapid  heart  shortens 
the  diastolic  period  and  interferes  with  ventricular  re- 
laxation, thereby  preventing  the  proper  filling  of  the 
ventricle  and  in  consequence  the  systolic  output  is  dimin- 
ished and  the  mass  movement  of  blood  impaired. 

Another  method  of  determining  myocardial  efficiency 
has  been  suggested  by  Masing^  who  notes  the  effect  of 
exercise  upon  the  relation  of  systolic  to  diastolic  pressure. 
After  exercise  a  normal  circulatory  apparatus  will  yield 
a  systolic  rise  of  greater  extent  than  the  diastolic  rise, 
i.e.,  the  pulse  pressure  is  increased,  while  after  exercise  a 
defective  myocardium  may  show  the  rise  in  both  pressures, 
but  they  will  tend  to  approximate  and  consequently  the 
pulse  pressure  will  be  reduced.  In  my  experience  this 
change  cannot  always  be  demonstrated,  although  in  certain 
cases  it  is  undoubtedly  so. 

^  Y.   Henderson  and   T.    B.    Barringer,   Am.   Jour.  Physiol.,  1913,  xxxi, 
p.  288. 

2  E.  Masing,  Deutsch.  arch.  f.  klin.  Med.,  1902,  Ixxiv. 


342  BLOOD-PRESSURE 

Graphically  we  may  express  the  change  as  follows: 

Normal  myocardium  Defective  myocardium 

__  ,  P.P.        35       ,  .  P.P.        40        ,  . 

Before  exercise.  .     g-p-  =  —  =  J^  -g-p-  =  _  =  i^ 

Af.  •  PP-       55       ,.  P.P.        30 

After  exercise.  .  .    g-p-  =  j^  =H  g-p;  =  135  ="  K 

In  this  the  increase  in  the  value  of  the  fraction  is  an  indi- 
cation of  efficient  heart,  while  the  decrease  in  the  value  of 
the  fraction  after  exercise  is  an  indication  of  inefficiency. 

In  my  own  practice  I  have  derived  much  satisfaction 
from  a  computation,  first  suggested  by  Gibson,  in  which  an 
effort  is  made  to  demonstrate  the  relative  work  and  velocity 
factors  of  the  cardiac  energy,  modified  to  meet  the  condi- 
tions met  in  auscultatory  determinations.^  This  is  based 
upon  the  following  propositions:  First,  the  normal  sys- 
tolic, diastolic,  pulse  pressure  relation  is  3  :  2: 1 ;  and  second, 
if  the  pulse  pressure  represents  the  systolic  output  (see 
page  137)  it  follows  that  it  must  also  be  the  most  important 
factor  in  determining  the  velocity  of  the  blood-stream, 
which  for  physical  reasons  must  bear  a  definite  relation  to 
the  volume  output  of  the  heart  and  to  the  caliber  of  the 
conduits — the  arteries — so  that,  if  other  factors  remain 
the  same,  it  is  not  a  difficult  matter  to  estimate  both  the 
velocity  and  also  the  work  of  the  heart  while  operating 
under  either  normal  or  abnormal  conditions. 

The  above  propositions  can  be  arranged  graphically  as 
follows. 2  For  example,  take  a  case  presenting  these  figures: 
S.P.  130,  D.P.  85,  P.P.  45,  P.R.  70;  then  -  P.P.  (45)  X  P.R. 
(70)  =  Velocity  (3100),  and  S.P.  (130)  X  P.R.  (70)  = 
Work  (9100). 

We  may  carry  our  calculations  further  and  state  that  the 

»  Interstate  Med.  Jour.,  p.  897,  xxi,  8,  July,  1914. 

*  F.  A.  Faught,  Interstate  Medical  Journal,  July,  1914. 


CARDIAC   DISEASE 


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Fig.  69. — Female.  Aged  sixty.  Typical  cardiac  neurasthenic.  Has 
been  in  the  hands  of  many  physicians  during  the  past  ten  years  with  indif- 
ferent results.  Complains  of  a  long  list  of  vague  and  variable  symptoms 
including  insomnia,  joint  pains,  globus  hystericus,  dyspnea,  heat-flashes, 
palpitation,  variable  appetite  and  nervousness. 

Physical  examination  shows  a  moderate  degree  of  chronic  myocarditis 
which  is  well  shown  in  the  chart  by  the  abnormally  large  pulse  pressure. 
At  no  time  during  observations  did  this  patient  show  any  marked  signs  of 
myocardial  weakness,  the  condition  being  more  one  of  instability. 

At  (A)  a  sharp  rise  in  systolic  and  pulse  pressure  was  accompanied  by  a 
number  of  dizzy  spells  and  a  tendency  to  faintness,  the  cause  for  which  was 
unexplained.  A  prompt  fall  in  pressure  resulted  from  an  administration 
of  atropin  with  strychnin,  followed  by  effect  obtained  at  (B),  due  to  better 
hygiene  and  systematic  out-door  exercise.  This  was  the  only  time  during 
the  observation  of  this  patient  that  the  symptoms  were  suggestive  of  myo- 
cardial overstrain.  This  is  the  type  of  case  which,  on  account  of  extreme 
personal  solitude,  and  the  avoidance  of  all  unnecessary  strain  that  would 
tend  to  upset  a  circulatory  equilibrium  will  go  on  for  years  and  may 
live  to  extreme  old  age  in  spite  of  the  cardiac-muscle  handicap. 

Fair  cardiac  efficiency  is  indicated  by  the  regularity  with  which  the  pulse 
pressure  follows  the  systolic. 


344  BLOOD-PRESSURE 

velocity  and  the  work,  as  estimated  by  the  above  formula, 
also  bear  a  definite  normal  relation  which  is  dependent 
entirely  upon  the  normal  relation  of  pulse  pressure  to  sys- 
tolic pressure  (and  that  this  relation  is  as  3:1,  while  in 
myocardial  cases  the  ratio  is  increased). 

Application. — Case  of  chronic  myocarditis  and  arterio- 
sclerosis. 

Before  treatment: 

S.P.  210,  D.P.  100,  PP.  110,  P.R.  104. 
S.P.  (210)  X  P.R.  (104)  =  Work  (21,840) 


P.P.(110)XP.R.(104)=Velocity(ll,440)  '  -ratiol:2. 
After  two  weeks'  treatment: 

S.P.  195,  D.P.  140,  P.P.  55,  P.R.  84. 

S.P.  (195)XP.R.  (84)=  Work  (14,580)   |  _      ,.    .   „ 

P.P.  (55)XP.R.  (84)  =  Velocity  (4,620)  J  ~  ^^^^^  ^•^• 
Here  under  the  proper  method  of  treatment  the  work 
velocity  was  greatly  benefited,  the  actual  work  reduced 
one-third,  so  that  while  the  heart  was  at  first  barely  able 
to  maintain  the  needs  of  the  case  under  serious  strain, 
accompanied  by  evident  signs  of  cardiac  distress,  after 
two  weeks  the  danger  of  acute  failure  of  the  circulation 
was  overcome  and  the  whole  complexion  of  the  case  altered 
for  the  better. 

Importance  of  Diastolic  Pressure. — From  his  study 
Stone  concludes  that  since  the  diastolic  pressure  measures 
the  peripheral  resistance,  it  is  a  better  index  of  hyper- 
tension than  is  the  systolic  pressure.  The  diastolic  pressure 
is  less  influenced  by  pathologic  factors  than  the  pulse 
pressure. 

Pulse  Pressure  in  Cardiac  Neuroses. — Stone  believes 
that   marked   variations    of   pulse    pressure    occurring   at 


CARDIAC    DISEASE  345 

short  intervals  (Fig.  66)  in  cases  with  cardiac  symptoms, 
are  very  suggestive  of  a  cardiac  necrosis. 

Blood-pressure  in  Auricular  Fibrillation. — Silverberg^ 
studied  eight  patients  all  of  whom  were  typical  examples 
of  this  variety  of  cardiac  irregularity,  all  of  which  showed  the 
wide  range  of  blood-pressure  which  an  individual  case  of 
auricular  fibrillation  may  possess.  He  found  that  the 
blood-pressure  reading  of  the  small  beats  varied  from  80  to 
160,  while  the  maximum  systolic  pressure  varied  between 
200  and  210. 

Paroxysmal  Tachycardia. — The  pulse  rate  may  be 
from  150  to  300,  the  heart  sounds  good  and  the  pulse  small, 
sometimes  the  pulse  rate  cannot  be  counted,  the  blood- 
pressure  is  usually  found  to  be  low,  probably  because  the 
shortness  of  diastole  does  not  allow  the  proper  filling  of  the 
ventricles;  the  venous  pressure  is  high.  In  the  intervals 
the  circulation  is  apparently  normal  (Krehl). 

Bradycardia. — The  effect  on  blood-pressure  is  variable, 
depending  on  the  cause  and  on  other  conditions  if  present. 
When  extreme,  blood-pressure  is  always  lowered;  patients 
with  dyspnea  cannot  exert  themselves,  and  even  change 
in  posture  may  precipitate  attacks  of  syncope  (Krehl). 

Finally,  in  close  relation  to  the  circulation  in  diseases 
of  the  heart,  as  has  been  found  by  Krehl  and  others,  are 
the  last  stages  of  arteriosclerosis.  Here  there  is  widespread 
dilatation  of  the  splanchnic  area  together  with  failure  of 
the  heart  to  respond  to  the  demands  made  upon  it;  this 
results  in  a  gradually  falling  blood-pressure,  when  thera- 
peutic measures  have  little  or  no  effect  (see  Terminal 
Hypertension) . 

1  Brit.  Med.  Jour.,  Apr.  6,  1912,  i,  2675. 


346 


BLOOD-PRESSURE 


Cardiac  Asthma.— This  term  imphes  a  severe  attack  of 
dyspnea  occmring  in  an  individual  having  heart  disease. 
During  the  attack  the  pulse  is  rapid,  soft  and  irregular 
in  force  and  rhythm.  The  blood-pressure  is  usually  below 
normal  during  the  height  of  the  attack,  speedily  regaining 
its  former  level  as  the  attack  subsides. 


I 


CHAPTER  XX 

RELATION  OF  BLOOD-PRESSURE  TO  SURGERY 

The  surgeon  has  not  been  as  rapid  in  the  adoption  of 
blood-pressure  studies  to  his  pathologic  problems  as  has  the 
general  physician,  neither  does  it  appear  that  the  two  stand 
upon  the  same  ground  in  regard  to  the  significance  of  the 
findings;  thus  many  medical  men  view  with  alarm  abnor- 
malities in  blood-pressure,  particularly  the  persistent  eleva- 
tion in  the  systolic,  when  found  in  cases  demanding 
operation,  whereas  the  surgeon  is  inclined  to  doubt  the 
truth  of  this  opinion,  so  that  he  often  underestimates 
the  value  of  preliminary  blood-pressure  examinations  in 
surgical  cases.  For  example,  the  active  practitioner  of 
medicine  as  a  matter  of  course  includes  a  series  of  blood- 
pressure  observations  in  his  general  survey  of  the  case 
and  often  depends  largely  upon  its  indications  to  determine 
the  condition  of  the  kidneys  and  circulation  in  relation 
to  the  risk  of  operation,  especially  in  determining  for  and 
against  operations  of  choice  {i.e.,  not  urgently  demanded). 
On  the  other  hand  many  surgeons,  some  of  wide  reputation, 
do  not  study  blood-pressure  at  all,  even  in  cases  evidently 
hazardous.  This  is  a  most  unfortunate  attitude,  and  in 
the  present  state  of  our  knowledge  of  the  subject  hardly 
tenable.  It  has  been  shown  beyond  a  question  of  doubt 
that  a  knowledge  of  blood-pressure  before,  during  and  after 
surgical   procedures,  especially  when   they  are  prolonged 

347 


348 


BLOOD-PRESSURE 


Fig.  70. — Female.  Aged  forty-five.  Moderate  chronic  nephritis.  Pro- 
longed operation.  Has  long  been  a  sufferer  from  chronic  pelvic  trouble. 
A  study  of  her  case  was  taken  up  because  of  urgent  need  for  operation  in 
the  presence  of  an  evident  renal  involvement,  as  shown  by  observation  at 
(A)  at  which  time  the  urine  showed  a  large  amount  of  albumin,  occa- 
sional hyaline  casts  and  a  normal  specific  gravity.  A  question  of  opera- 
tion hinged  upon  the  condition  of  the  kidneys  so  that  between  (A)  and 
{B)  sweats  and  other  eliminative  measures  were  instituted,  with  the  effect 
on  pressure  as  shown.  The  urine  practically  cleared  up  and  the  phtha- 
lein  test  showed  first  hour  50  per  cent.,  second  20  per  cent.,  and  the 
urinary  excretion  for  fourteen  hours  preceding  operation  was  44  ounces. 

Operation  was  performed  at  {B),  was  very  extensive,  and  although  cover- 
ing several  hours,  the  patient  was  returned  to  her  room  in  fair  condition. 


RELATION    OF  BLOOD-PRESSURE   TO    SURGERY  349 

and  trauma  is  great;  when  the  individual  is  obviously  in  a 
poor  condition  and  predisposed  thereby  to  shock,  is  of 
definite  value,  and  its  estimation  may  assist  materially 
in  preventing  untoward  results.  Even  admitting  the 
tendency  in  any  new  subject  to  go  to  extremes,  it  is  evi- 
dent that  there  must  be  a  middle  ground  which,  when 
occupied  by  the  surgeon,  will  vindicate  this  test  in  con- 
nection with  surgical  procedures. 

That  the  surgeon  is  gradually  turning  to  a  consideration 
of  the  sphygmomanometer  and  its  findings  is  shown  by 
the  recent  surgical  literature  upon  shock,  which  includes 
a  study  of  the  relation  of  blood-pressure  to  this  condition. 


In  spite  of  this  the  urinary  excretion  fell  to  7  ounces  in  twenty-four  hours 
and  was  reported  as  resembling  that  in  eclampsia.  The  systolic  pressure 
was  120  and  the  pulse  pressure  in  the  next  twenty-four  hours  fell  to  20, 
indicating  a  myocardial  and  not  a  nephritic  involvement.  At  this  point 
hot  packs  and  sweating  would  undoubtedly  have  occasioned  a  fatal  termina- 
tion, whereas  active  hypodermic  stimulation  by  adrenalin  and  caffein  resulted 
in  a  retiu-n  of  cardiac  equiUbrium,  an  increase  in  kidney  output  and  a  normal 
progress  until  (C),  when  several  hours  before  the  observation  recorded,  the 
patient  became  suddenly  pale  and  had  profuse  perspiration  with  an  imper- 
ceptible pulse.  Oxygen  and  hypodermic  treatment  tided  her  over  this 
crisis  and  a  thorough  examination  g,t  the  time  of  the  blood-pressure  test  (C), 
failed  to  show  that  this  attack  had  any  effect  upon  the  patient's  convales- 
cence. Subsequent  investigation  showed  that  the  attack  was  probably  one 
of  ptomain  poisoning,  as  the  patient  had  eaten  fish  for  the  first  time  on  that 
day,  and  was  reported  as  having  had  several  attacks  in  the  past  from  the 
same  cause. 

Several  points  stand  out  significantly  in  this  case: 

First. — The  beneficial  effect  of  eliminative  measures  preliminary  to  opera- 
tion in  cases  of  evident  renal  involvement. 

Second. — The  information  gained  by  blood-pressure  test  immediately 
after  operation  which  was  the  only  means  of  determining  the  true  cause  of 
the  grave  symptoms  shown. 

Third. — The  fact  that  such  a  cardiovascular  system  can  withstand  the 
effect  and  shock  of  prolonged  operation  without  suffering  apparent  damage 
as  shown  by  the  subsequent  records. 

Fourth. — The  mental  relief  afforded  those  in  charge  by  eliminating  the 
possibility  of  embolism  as  the  cause  of  the  attack  occurring  at  (C). 


350  BLOOD-PRESSURE 

and  upon  which  all  contending  factions  admit  the  definite 
and  often  intimate  relation  between  blood-pressure  and 
shock,  whether  as  cause  or  effect. 

A  single  example  which  recently  came  to  the  writer's 
attention  may  serve  to  demonstrate  that  there  are  times 
when  the  surgeon  must  employ  the  blood-pressure  test,  and 
when  such  study  will  contribute  largely  to  the  successful 
outcome  of  the  case  (Fig.  70).  A  woman  of  about  forty- 
five,  suffering  from  the  effect  of  an  old  pelvic  inflammatory 
condition,  was  found  to  have  a  moderate  degree  of  con- 
tracted kidney  as  shown  by  repeated  urinalysis,  and  the 
blood-pressure,  which  ranged  between  180  and  200  systolic. 
Operation  was  indicated  most  urgently  on  account  of 
intense,  prolonged  and  frequent  attacks  of  pain,  render- 
ing the  patient  a  semi-invalid.  Preliminary  preparation 
of  a  dietetic  and  hygienic  nature  showed,  on  the  day  before 
the  operation,  a  phthalein  output  of  50  per  cent.,  first 
hour,  with  20  per  cent,  second  hour,  a  copious  urinary 
excretion  and  a  blood-pressure  of  systolic  170,  diastolic 
110,  pulse  pressure  60.  Many  adhesions  occasioned  a  pro- 
longed and  difficult  operation,  followed  by  some  degree 
of  shock,  so  that  during  the  first  succeeding  twenty-four 
hours  the  urinary  output  was  7  ounces,  and  was  reported 
on  examination  to  be  like  that  found  in  eclampsia,  sug- 
gesting the  supervention  of  uremia. 

A  blood-pressure  determination  gave  the  following: 
systolic  120,  diastolic  100,  pulse  pressure  20,  pulse  rate 
104,  with  an  absence  of  the  second  and  third  auscultatory 
phenomena  over  the  brachial;  these  together  with  the  low 
urinary  excretion,  pointing  to  a  cardiovascular  and  7iot 
a   nephritic   condition.     The   prompt   intravenous   use   of 


RELATION    OF   BLOOD-PRESSURE    TO    SURGERY  351 

adrenalin,  and  the  hypodermic  administration  of  caffein 
and  digitalis  resulted  in  a  prompt  rise  in  systolic  and  an 
increase  in  pulse  pressure,  with  a  return  of  the  second  and 
third  (cardiac  strength)  sounds.  These  changes  were 
coincident  with  a  marked  increase  in  urine  output,  and 
abatement  of  the  pathologic  urinary  findings,  so  that  on 
the  third  day  the  blood-pressure  record  was  systolic  130, 
diastolic  85,  pulse  pressure  45,  pulse  rate  92,  while  on  the 
fifth  day  the  urine  was  over  40  ounces  in  twenty-four  hours, 
almost  normal  by  the  laboratory  report  and  the  patient 
in  most  excellent  condition. 

The  points  to  be  emphasized  here  are: 

1.  The  chronic  nephritis  prior  to  operation. 

2.  The  normal  phthalein  output. 

3.  The  scant,  eclamptic  urine  with  great  circulatory 
depression,  the  latter  being  the  only  definite  indication  that 
the  difficulty  was  not  urem^ic  but  cardiovascular,  and  finally 
the  prompt  response  following  treatment  from  the  latter 
standpoint  only. 

Clinical  and  experimental  study  has  demonstrated  many 
facts  in  connection  with  the  relation  of  blood-pressure 
variations  to  the  various  surgical  procedures,  incidents 
and  accidents.  Possibly  the  reason  for  the  failure  of  the 
surgical  fraternity  to  adopt  and  interpret  blood-pressure 
findings  is  because  they  have  so  far  failed  to  thoroughly 
study  this  relation.  Continued  study  of  routine  blood- 
pressure  records  will  eventually  force  the  conclusion  that 
there  is  often  a  definite  relation  between  the  height  of 
the  blood-pressure  and  variations  in  its  several  factors, 
to  the  general  clinical  picture,  so  that  a  proper  interpreta- 
tion of  blood-pressure  in  relation  to  other  symptoms  may 


352  BLOOD-PRESSURE 

become  of  signal  value  in  following  or  in  predicting  post- 
operative complications. 

It  is  no  argument  against  the  employment  of  this  test 
that  we  do  not  yet  know  precisely  the  nature,  causes  and 
mechanics  of  shock;  it  rather  enhances  its  value  in  that  it 
throws  another  safeguard  around  the  extreme  case. 

That  this  point  is  beginning  to  be  appreciated  is  shown 
by  the  writing  of  at  least  one  well-known  surgeon^  who 
states  that  when  the  systolic  blood-pressure  falls  to  100  or 
lower  it  is  time  to  consider  emergency  measures,  and  that 
often  in  the  absence  of  any  other  signs  of  impending  shock 
there  is  a  more  or  less  rapidly  falling  systolic  pressure; 
also  he  believes  that  many  cases  of  collapse  following  the 
removal  of  the  patient  from  the  operating  room  may  be 
avoided  by  the  comparison  of  the  observations  of  blood- 
pressure  taken  before  and  after  operation. 

It  has  also  been  shown  that  when  primarily  the  blood- 
pressure  is  abnormally  high  or  abnormally  low,  complica- 
tions are  more  apt  to  ensue  and  that  one  should  be  on  guard 
against  thrombosis,  embolism,  pneumonia,  nephritis,  and 
bronchitis^  under  such  conditions. 

In  the  average  surgical  case,  lethal  accidents  are  either 
the  result  of  acidosis  or  the  paralyzing  effect  of  the  anes- 
thetic upon  the  cardiac  or  the  respiratory  centers,  so  that 
in  prolonged  operations  the  study  of  the  blood-pressure 
during  the  operation  may  be  a  valuable  guide  in  indicating 
the  reaction  of  the  patient  while  under  the  anesthetic. 
In  other  words  the  persistence  of  a  fair  average  systolic 
level  and  an  adequate  pulse  pressure  is  indicative  of  a 

1  Joseph  C.  Bloodgood,  Penna.  Med.  Jour.,  January,  1912,  p.  256. 
«G.  W.  Crile,  Jour.  A.  M.  A.,  May  3,  1913,  Ix,  No.  22,  p.  1737. 


RELATION    OF  BLOOD-PRESSURE   TO    SURGERY  353 

better  factor  of  safety  than  either  a  sudden  rise,  or  gradual 
or  marked  fall  in  systolic  pressure,  or  a  diminution  in  the 
pulse  pressure. 

The  employment  of  the  sphygmomanometer  would  seem 
to  have  placed  the  administration  of  anesthetics  upon  a 
firmer  foundation  since,  while  our  judgment  in  regard 
to  the  condition  of  the  patient  under  operation  may  be 
modified  by  a  knowledge  of  the  pathologic  condition  leading 
up  to  the  operation  and  by  the  general  physical  condition 
of  the  patient  at  the  beginning  of  the  operation,  neverthe- 
less it  has  been  borne  out  by  clinical  experience  that  the 
blood-pressure  test  is  of  value  as  an  indication  of  safety 
during  prolonged  and  extreme  operations,  and  it  is  hoped 
that  in  a  short  time  the  careful  surgeon  will  show  a  greater 
tendency  to  the  routine  of  employment  of  this  test,  and  by 
applying  the  knowledge  which  we  now  possess  in  relation 
thereto,  add  further  to  the  enlightenment  of  this  important 
subject. 

APPLICATION  OF  THE  TEST  TO  SURGICAL  CASES 

Blood-pressure  observations  can  usually  be  made  by  the 
anesthetist,  although  the  undivided  attention  of  an  assist- 
ant, either  a  nurse  or  student  trained  to  make  these  observa- 
tions, should  be  used  whenever  possible.  Observations 
made  during  surgical  operations  should  occur  at  from  two- 
to  five-minute  intervals  while  an  expert  assistant  can  give 
reports  of  blood-pressure  once  every  minute. 

In  grave  cases  the  value  of  the  test  becomes  greater  as 
the  interval  of  observation  is  shortened,  for  it  is  possible  for 
serious  changes  in  the  circulation  to  occm'  in  a  very  short 
space  of  time.     The  observation  to  be  of  greatest  service 

23 


354  BLOOD-PRESSURE 

should  be  charted  and  kept  in  view  of  the  surgeon.  Changes 
in  the  auscultatory  phenomena  should  also  be  reported 
to  the  surgeon  and  to  the  anesthetist.  The  value  of  these 
observations  lies  not  only  in  the  facility  with  which  danger- 
ous alterations  in  blood-pressure  may  be  detected,  but  also 
in  the  fact  that  the  effect  of  restorative  and  stimulating 
measures  may  be  noted,  so  that  efficient  dosage  may  be 
employed.  A  falling  systolic  pressure  with  a  rising  pulse 
rate  is  an  indication  for  immediate  action,  while  a 
diminution  in  pulse  pressure,  if  progressive,  is  an  indi- 
cation of  a  failing  circulation,  usually  attributable  to  the 
myocardium. 

In  the  study  of  blood-pressure  under  anesthetics  it  is 
necessary  to  obtain  the  patient's  normal  systolic  pressure 
before  the  anesthesia  is  begun,  and  this  should,  if  possible, 
be  obtained  the  day  before,  or  at  least  previous  to  the 
patient's  final  preparation  and  appearance  in  the  operating 
room.  Observations  made  immediately  before  anesthesia 
will  frequently  show  an  abnormally  high  pressure  and  an 
accelerated  pulse  rate,  which  is  accounted  for  by  the 
stimulating  effect  of  excitement  and  fright  on  the  car- 
diomotor  and  vasomotor  centers. 

It  must  also  be  borne  in  mind  that  the  blood-pressure 
level  will  be  affected  by  rest  in  bed,  and  by  restricted  diet 
which  usually  precedes  surgical  operations,  so  that  due 
allowance  should  be  made  for  these  influences. 

In  order  to  intelligently  interpret  the  results  of  sphygmo- 
manometry  the  surgeon  should  know  the  effect  of  the 
ordinary  steps  of  surgical  procedure  upon  blood-pressure 
as  compared  with  the  extraordinary  and  dangerous  manifes- 
tations resulting  from  excessive  trauma,  hemorrhage,  etc. 


RELATION    OF   BLOOD-PRESSURE    TO    SURGERY  355 

Pain  causes  a  temporary  rise  in  blood-pressure.  Ab- 
dominal pain,  in  which  the  splanchnic  nerves  are  involved, 
greatly  increases  the  pressure  on  account  of  the  resulting 
constriction  of  the  splanchnic  vessels.  H.  Curschmann^ 
believes  that  by  the  sphygmomanometer  we  may  be  able 
to  differentiate  between  the  several  sources  of  abdominal 
pain,  and  cites  instances  where  the  pain  from  gastric  and 
intestinal  crises,  as  in  tabes  and  in  lead  colic,  caused  the 
pressure  to  run  up  to  170  to  200  mm.,  to  drop  again  to 
normal  as  soon  as  the  pain  ceased,  whereas  in  pain  from 
gastric  ulcer,  gall-stones  and  appendicitis  there  was  only 
a  moderate  increase. 

Fear. — As  fear,  apprehension  and  mental  excitement  are 
usually  accompanied  by  a  sudden  increase  in  pulse  rate,  so 
the  systolic  pressure  tends  to  rise  from  10  to  20  mm.  above 
the  average.  If  the  element  of  fear  is  sufficiently  pro- 
found to  induce  shock,  there  may  be  a  fall  in  systolic  pres- 
sure amounting  to  60  mm.  in  a  few  minutes.^ 

INFLUENCE  OF  OPERATIVE  PROCEDURES 

Skin  Incision. — Incision  of  the  skin,  except  in  profound 
anesthesia,  results  in  a  reflex  vasoconstriction  which  shows 
itself  by  slight  rise  in  systolic  pressure,  amounting  ordinarily 
to  from  5  to  10  mm.  Hg. 

Incision  of  the  Peritoneum. — This  procedure  causes  a 
sudden  and  sharp  rise  in  systolic  pressure,  which,  though 
momentary,  is  more  marked  than  that  when  the  skin  is 
incised;  extensive  trauma  of  the  peritoneum  is  prone  to 
cause  a  marked  systolic  fall,  the  degree  and  extent  of  de- 

1  Miinch.  med.  Wochen.,  Oct.  16,  1907. 

2  Bloodgood,  Internal.  Jour.  Surg.,  September,  1913,  xxvi. 


356  BLOOD-PRESSURE 

pression  depending  upon  the  extent  and  degree  of  trauma 
and  exposure  to  which  the  viscera  are  subjected  (degree 
of  shock). 

Aspiration  of  Fluid  from  the  Chest   and   Abdomen. — 

Capps^  and  Lewis^  have  analyzed  the  results  of  extensive 
observations  of  the  blood-pressure  before,  during  and 
after  paracentesis  and  have  classed  them  under  two  heads. 

(a)  Constant  Features. — Following  the  transient  rise  inci- 
dent to  spine  puncture  or  incision,  there  is,  during  drainage 
of  fluid,  a  marked  fall  in  arterial  pressure,  averaging  32  mm. ; 
the  depth  of  depression  is  usually  reached  after  the  needle 
has  been  withdrawn,  although  it  may  occur  at  any  time. 
The  greatest  fall  noted  by  these  observers  was  62  mm., 
which  followed  the  removal  of  2000  c.c.  of  fluid.  Occasion- 
ally the  fall  is  very  slight.  The  final  pressure  taken  an 
hour  after  the  end  of  the  operation  averages  a  fall  of  12 
mm.  This  decrease  corresponds  to  an  average  fall  in 
intra-abdominal  pressure,  after  tapping,  of  10  to  14  mm. 
as  noted  by  Querin. 

(b)  Special  Influences. — The  rate  of  withdrawal  of  fluid, 
rather  than  the  amount,  appears  to  be  the  important 
factor  influencing  systolic  pressure,  being  greater  the  more 
rapid  the  withdrawal.  External  pressure  upon  the  ab- 
dominal wall  after  drainage  reduces  the  final  total  fall  by 
from  5  to  20  mm.  Posture  is  important,  as  normally  the 
pressure  is  higher  when  sitting  than  when  recumbent. 
At  the  end  of  paracentesis  a  change  from  the  sitting  to  the 
prone  position  increases  the  pressure  G  to  20  mm.  and  this 
rise  is  more  marked  in  those  cases  which  suffer  the  most 

^Jour.  A.  M.  A.,  xlviii,  1,  1907. 

2  Am.  Jour.  Med.  Sci.,  December,  1908. 


RELATION    OF   BLOOD-PRESSURE   TO    SURGERY  357 

from  the  effects  of  the  operation.  These  changes  are  also 
noted  during  the  removal  of  purulent  effusions.  Alarming 
symptoms  appear  more  frequently  during  the  removal  of 
pleural  effusions.  Capps  and  Lewis  believe  that  this  blood- 
pressure  change  is  not  purely  the  result  of  alteration  in 
intrathoracic  pressure  but  is  due  to  the  activity  of  two 
reflexes,  one  a  cardio-inhibitory  and  the  other  a  vasodilator. 
It  is  believed  that  the  effect  of  these  reflexes  can  be 
materially  modified  if  sufficient  care  is  exercised  in  the 
introduction  of  the  needle,  so  as  to  avoid  wounding  the 
visceral  pleura. 

Induced  Pneumothorax. — F.  C.  Smith^  has  studied  the 
influence  of  induced  pneumothorax  on  the  blood-pressure 
in  sixteen  cases  in  which  the  effect  of  the  operation  itself 
was  excluded  by  taking  the  pressure  at  other  times  and 
extending  them  over  varying  periods  up  to  more  than  a 
year  after  the  operation.  No  important  changes  in  blood- 
pressure  were  noted. 

Gynecologic  Operations.— ReUable  observations  show 
that  manipulations  of  the  pelvic  organs  cause  a  rise  in 
systolic  pressure  and  that  this  rise  is  proportionate  to  the 
severity  of  the  traumata,  unless  shock  intervenes.  The 
reports  of  observers  employing  chloroform  as  an  anesthetic 
are  of  little  value  because  of  the  uniform  depressing  effect 
of  the  chloroform  itself. 

Cord  and  Brain  Operations. — Operative  procedures  for 
decompression  are  attended  with  added  danger,  because  of 
the  primary  lowering  of  systolic  pressure  which  follows  the 
escape  of  cerebrospinal  fluid.  ^     The  amount  of  subsequent 

1  Jour.  A.  M.  A.,  May  29,  1915,  Ixiv,  22. 

2  E.  D.  Fisher,  Jour.  A.  M.  A.,  Aug.  3,  1912,  lix,  5,  p.  395. 


358  BLOOD-PRESSURE 

circulatory  depression  will  depend  upon  the  nature,  dura- 
tion and  extent  of  the  operative  procedures  and  the  degree 
of  the  trauma  or  the  extent  of  the  disease  preceding  opera- 
tion. It  is  stated  by  Crile  that,  under  normal  conditions, 
dural  incision  per  se  has  little  if  any  effect  upon  the  systolic 
blood-pressure  curve,  but  that  irritation  of  the  brain  or 
cord  covering  by  sponging,  packing,  etc.,  is  usually  oc- 
casioned by  a  sharp  fall  in  systolic  pressure. 

Lumbar  Puncture. — After  the  primary  rise  coincident 
with  skin  puncture  which  occurs  in  the  conscious  patient, 
the  withdrawal  of  fluid  tends  to  reduce  systolic  pressure, 
but  the  net  result  of  lumbar  puncture  is  a  rise,  averag- 
ing 20  mm.  for  at  least  twenty  minutes  succeeding  the 
removal.^ 

The  type  of  blood-pressure  curve  in  lumbar  puncture  in 
individuals  with  increased  intracranial  tension  of  supra- 
tentorial  origin  is  the  same  as  in  normal  individuals,  while 
in  subtentorial  cases  the  primary  rise  is  more  sustained. 

The  blood-pressure  curve  in  cases  subjected  to  high 
spinal  anesthesia  shows  a  primary  sharp  rise  accompanying 
and  immediately  following  the  puncture,  after  which,  as 
the  anesthetic  effect  upon  the  thoracic  muscles  occurs, 
there  is  a  fall,  which  is  not  lost  until  the  paralyzing  effects 
of  the  drug  have  passed  off. 

Geo.  G.  Smith^  has  noted  a  fall  of  as  much  as  100  mm. 
Hg.,  after  the  induction  of  high  spinal  anesthesia  In 
several  cases  the  systolic  level  fell  to  45  mm.  Hg.  These 
extremely  low  pressures  occurred  only  in  a  small  propor- 
tion of  spinal  anesthesias;  in  many  instances  the  systolic 

•  H.  T.  Gray  and  L.  Parsons,  Quart.  Jour.  Med.,  April,  1912,  9. 
'  Boston  Med.  and  Surg.  Jour.,  Sept.  30,  1915,  clxxiii,  141,  p.  502. 


RELATION    OF   BLOOD-PRESSURE    TO    SURGERY  359 

pressure  fell  to  75  mm.  Hg.  Many  of  the  cases  showed  a 
marked  reduction,  exhibiting  signs  of  shock.  The  pulse 
usually  remained  between  60  and  90,  and  did  not  increase 
in  rate  as  the  blood-pressure  fell.  These  low  pressures 
usually  appeared  in  from  ten  to  twenty  minutes  after  the 
introduction  of  the  drug,  and  remained  for  from  ten  to 
fifteen  minutes  after  the  action  of  the  drug  had  passed  off. 
Smith  summarizes  our  knowledge  of  the  effects  of  spinal 
anesthesia  by  the  usual  anesthetics  as  follows: 

1.  The  blood-pressure  may  be  lowered  as  much  by  spinal 
anesthesia  as  by  section  of  the  cord  in  the  cervical  region. 

2.  The  greatest  fall  follows  injection  of  the  anesthetic 
in  the  thoracic  region,  where  the  vasomotor  fibers  which 
supply  the  splanchnic  area  leave  the  cord. 

3.  This  part  of  the  vasomotor  mechanism  is  the  first  to 
be  affected  by  the  drug  when  the  injection  is  made  in  the 
lumbar  region. 

4.  The  extent  of  diffusion  of  the  drug  within  the  dural 
sac  appears  to  be  influenced  more  by  the  bulk  of  the  solu- 
tion injected  than  by  any  other  factor. 

5.  A  given  amount  of  drug  in  a  concentrated  solution 
diffuses  less,  and  consequently  lowers  blood-pressure  less, 
than  does  the  same  amount  of  drug  in  a  more  dilute  solution. 

6.  The  greatest  effect  upon  blood-pressure  is  noted  when 
adrenalin  is  combined  with  novocain. 

7.  Entire  fixation  of  the  drug  does  not  take  place  within 
twenty  minutes  after  the  time  of  injection. 

8.  When  a  solution  of  greater  specific  gravity  than  spinal 
fluid  is  used,  the  extent  of  diffusion  may  be  increased  by 
gravity. 

9.  Attempts  to  raise  the  blood-pressure  by  the  intraven- 


360 


BLOOD-PRESSURE 


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Fia.  71. — Male.  Aged  forty-two.  Hemorrhage  from  gastric  ulcer.  Ex- 
mination  prior  to  hemorrhage  (A)  shows  a  slightly  elevated  systolic  pres- 
Bure  in  one  of  rather  active  physical  and  mental  habits.  Pressure  recorded 
at  (B)  was  made  a  few  hours  after  a  copious  hemorrhage  from  gastric  ulcer, 
at  which  time  the  patient  was  almost  totally  blind,  showed  extreme  pallor  and 
apathy,  with  a  rapid-running  pulse,  and  hurried  gasping  respiration.  By 
actual  measurement  the  amount  of  blood  lost  within  an  hour  or  two  was  not 
less  than  a  quart.  This  is  the  characteristic  curve  of  massive  hemorrhage 
in  which  the  greatest  reduction  first  occurs  in  the  systolic  pressure  resulting 
in  an  extremely  small  pulse  pressure  immediately  following.  Circulatory 
balance  is  rapidly  established  by  a  reduction  in  diastolic  pressure  with  or 
without  much  change  in  systolic  pressure,  resulting  in  a  rapid  return  to  a 
safe  pulse  pressure  usually  several  days  before  the  systolic  pressure  again 
approaches  normal. 


RELATION  OF  BLOOD-PRESSURE  TO  SURGERY       361 

ous  injection  of  pituitrin  or  adrenalin  during  spinal  anes- 
thesia give  only  a  small  and  very  transitory  rise. 

10.  Adrenalin  alone  injected  into  the  spinal  canal  was 
found  to  have  no  effect  on  blood-pressure. 

Hemorrhage. — The  amount  of  reduction  in  systolic 
pressure  caused  by  hemorrhage  as  a  rule  bears  a  direct 
relation  to  the  amount  of  blood  lost  and  to  the  rapidity 
with  which  the  loss  of  blood  occurs.  An  exception  to  this 
is  seen  in  cerebral  hemorrhage  where  increased  intracranial 
pressure  occasions  great  elevation. 

John  B.  Briggs^  has  reported  intracranial  hemorrhage 
with  a  systolic  pressure  of  400  mm.  Hg.  In  the  usual 
acute  hemorrhage,  as  from  external  wounds,  from  gastric 
ulcer  or  during  typhoid  fever,  in  tuberculosis  and  in  epis- 
taxis,  the  systolic  pressure  may  fall  so  low  as  to  endanger 
life.  This  complication  becomes  more  serious  when  the 
hemorrhage  is  engrafted  upon  a  weakened  state  caused 
by  previous  hemorrhage,  or  during  collapse  when  the  vaso- 
motor system  is  greatly  weakened  or  paralyzed.  It  is 
noteworthy  that  the  fall,  even  when  marked,  is  transient 
unless  the  hemorrhage  continues,  so  that  the  value  of  this 
sign  diminishes  in  proportion  as  the  time  between  the 
hemorrhage  and  the  observation  is  prolonged  (Fig.  71). 
It  is  fortunate  that  all  hemorrhages,  except  those  coming 
from  very  large  vessels,  tend  to  become  arrested  long  before 
great  danger  due  directly  to  loss  of  blood  occurs.  The  fall 
of  pressure  from  hemorrhage  is  not  as  great  as  the  actual 
amount  of  blood  lost  would  indicate;  this  is  due  to  the 
reflex  augmentation  of  cardiac  output  and  also  to  a  rapid 
drawing  upon  the  fluid  in  the  lymphatic  system.     If  arrest 

^  Johns  Hopkins  Hosp.  Bulletin,  Aug.  10,  1910. 


362  BLOOD-PRESSURE 

of  hemorrhage  fails  to  occur  before  these  reserves  are  ex- 
hausted, then  the  circulation  fails,  because  the  mechanical 
function  of  the  heart  cannot  be  carried  out  (see  also  shock). 
In  other  words  the  amplitude  of  cardiac  contraction 
decreases  chiefly  because  of  the  lack  of  sufficient  fluid  in  the 
actual  system  upon  which  to  operate.  Henderson  and 
Barringer^  ascribe  this  result  to  the  evident  fact  that  the 
venous  pressure  is  greatly  lowered,  and  conclude  that  the 
so-called  ''critical  factor"  in  hemorrhage  is  dependent 
largely  upon  a  failure  of  venous  supply  to  the  right  heart, 
which  results  in  failure  of  the  circulation  as  a  whole. 
On  the  other  hand,  it  may  be  that  lowered  venous  pressure 
decreases  the  heart  output  indirectly  by  lessening  pulse- 
pressure  on  the  arterial  side,  thereby  reducing  the  rate  and 
volume  of  actual  flow,  which,  being  inadequate  to  maintain 
the  nutrition  of  the  important  centers,  contributes  to  the 
fatal  termination. 

Diagnosis  of  Concealed  Hemorrhage. — Carl  J.  Wiggers^ 
recommends  a  frequent  determination  of  the  pulse-pres- 
sures in  cases  of  suspected  internal  hemorrhage,  believing 
that  frequent  estimation  of  the  blood-pressure  in  suspected 
hemorrhage  is  of  great  value  in  differentiating  this  complica- 
tion from  others  also  accompanied  by  a  falling  pressure. 
He  has  found  that  almost  invariably  a  progressive  de- 
crease in  pulse-pressure  accompanied  by  an  acceleration 
in  pulse-rate,  occurring  after  surgical  procedures,  is  indic- 
ative of  continued  bleeding  and  that  the  converse,  if  per- 
sistent after  several  observations,  indicates  a  cessation  of 
the  bleeding.     He  recommends  that  the  following  series  of 

'  Loc.  cit. 

'^  Arch.  Int.  Med.,  September,  1910  and  Arch.  Int.  Med.,  July,  1914 


RELATION    OF   BLOOD-PRESSURE   TO    SURGERY  363 

diagnostic  features  be  considered  in  cases  of  suspected  or 
evident  internal  hemorrhage. 

In  arrested  hemorrhage  the  pulse  pressure  tends  to  be 
abnormally  large.  If  the  respiration  undergoes  little  or 
no  change,  the  following  deductions  may  be  drawn:  (a) 
A  progressive  decrease  in  pulse  pressure  with  a  decrease 
in  the  product  of  the  pulse  pressure  and  the  pulse  rate, 
indicates  a  continuance  of  the  bleeding.  (6)  An  increase 
in  both,  if  permanent,  after  several  determinations,  indi- 
cates a  cessation  of  hemorrhage,  (c)  A  temporary  increase 
of  both  followed  by  a  marked  decrease  as  shown  by  sub- 
sequent examinations,  indicates  an  exacerbation.  These 
points  have  been  experimentally  proven  by  animal  research. 

In  all  operations  control  of  hemorrhage  is  an  important 
factor  in  maintaining  blood-pressure.  When  hemorrhage 
is  slight  and  well  controlled  the  effect  on  pressure  is  usually 
unimportant  and  does  not  call  for  special  treatment.  On 
the  other  hand,  operations  accompanied  by  considerable 
bleeding  may  result  in  severe  and  dangerous  hypotension. 
The  tendency  to  shock  is  greatly  increased  by  hypotension 
from  any  cause  during  anesthesia,  but  if  shock  is  success- 
fully combated,  pressure  soon  returns  to  a  safe  level. 

INFLUENCE  OF  ANESTHETICS  ON  BLOOD-PRESSURE 

Discussing  the  mechanism  of  the  action  of  anesthetics  on 
blood-pressure  Guy,  Goodall  and  Reid^  remark  that 
blood-pressure  may  be  lowered  by  (1)  depression  of  the 
heart;  (a)  by  vagus  inhibition,  either  by  direct  stimulation 
of  center  by  the  drug,  or  by  reflex  stimulation  through  the 
nervous  system;   (6)  by  weakening  of  the  heart  muscle. 

^  Edinburgh  Med.  Jour.,  August,  1911. 


364 


BLOOD-PRESSURE 


(2)  Dilatation  of  the  vessel  wall  or  paralysis  of  vasomotor 
tone.  Blood-pressure  may  be  elevated  by  (1)  stimulation 
of  the  heart;  (a)  by  excitement;  (b)  by  stimulation  of  the 
heart  by  the  drug.  (2)  Stimulation  of  the  vasomotor 
centers;  (a)  by  the  action  of  the  drug;  (b)  by  asphyxia. 


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Fig.  72. — Ether  anesthesia — laparotomy.  Aged  twenty-three.  {A )  Anes- 
thetic begun.  iJS)  Anesthesia  complete.  (C)  Skin  incision.  (D)  Peritoneal 
cavity  opened.     (£)  Peritoneum  closed.     {¥)  Anesthesia  discontinued. 


Experiment  and  clinical  study  show  that  the  different 
anesthetics  in  general  use  affect  the  circulation  and  blood- 
pressure  in  different  ways,  and  that  the  extent  of  the  de- 
pressing  effect   of   the   anesthetic   on   blood-pressure   de- 


RELATION  OP  BLOOD-PRESSURE  TO   SURGERY 


365 


termines  in  a  great  measure  the  relative  danger  of  that 
anesthetic  and  its  tendency  to  produce  shock. 

In  the  following  paragraphs  an  effort  has  been  made  to 
indicate  as  far  as  is  known  the  action  of  different  anesthetics 


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Fig.  73. — Anesthetics.  Experimental  use  of  chloroform  in  a  male 
aged  thirty-two.  Complete  anesthesia  induced.  Anesthetic  begun  at  (A), 
complete  at  (B),  and  terminated  at  (C).  Duration  of  anesthesia  eleven 
minutes.  Note  the  absence  of  usual  rise  in  pulse  rate  and  systolic  pressure 
incident  to  mental  excitement  before  the  administration  of  the  anes- 
thetic, the  sharp  rise  in  pulse  rate  at  the  onset  and  the  steady  and 
rather  marked  fall  in  systolic  pressure  and  pulse  rate  throughout  the 
administration  together  with  a  return  to  approximately  normal  pulse  as 
the  case  regained  consciousness. 

and  to  show  what  blood-pressure  changes  may  be  expected 
to  occur  under  them. 

Ether. — Ether  does  not  occasion  any  great  alteration  in 
blood-pressure.  The  administration  of  ether  may  cause  a 
primary  rise  or  a  fall,  or  it  may  maintain,  as  in  most  cases, 
a  constant  level  (see  Fig.  72).  It  causes  more  rapid  and 
more  forcible  cardiac  action,  with  dilatation  of  the  smaller 


366 


BLOOD-PRESSURE 


vessels,  the  latter  effect  probably  counteracting  the  former, 
thereby  contributing  to  the  maintenance  of  a  constant 
blood-pressure  level.  The  development  of  shock  under 
ether  is  accompanied  by  great  systolic  depression  from 
which  subsequent  recovery  is  slow.^ 


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Fig,  74. — Nitrous  oxid  anesthesia.  Male.  Aged  thirty-one  years. 
Note  rapid  and  sharp  rise  in  all  pressures  incident  to  the  administration 
of  the  drug  (A  to  B)  and  rapid  fall  to  a  point  approximating  the  initial 
pressures  at  the  end  of  the  administration.  The  great  increase  in  pulse 
pressures  here  is  largely  due  to  the  sharp  rise  in  systolic  pressure  as  the 
diastolic  remained  practically  stationary  throughout  the  administration. 
This  is  a  condition  which  is  characteristically  met  in  nearly  all  cases  of 
nitrous  oxid  anesthesia. 

Chloroform. — Almost  without  exception,  chloroform 
causes  a  reduction  in  blood-pressure  amounting  to  10 
or  20  mm.  (see  Fig.  73),  the  degree  of  depression  depending 

1  H.  P.  Fairlie,  Lancet,  Feb.  28,  1914,  i.  No.  4722. 


RELATION    OP  BLOOD-PRESSURK   TO    SURGERY 


367 


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Fig.  75. — Nitrons  oxid  anesthesia.  Young  adult.  Extraction.  Dura- 
tion of  administration  four  minutes.  Note  extra  strain  thrown  upon  heart 
muscle  as  shown  by  over  50  per  cent,  increase  in  pulse  pressure.  Also 
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Stamp.  Sixteen  administrations  of  from  two  and  one-half  to  seven  minutes' 
duration  in  subjects  between  fourteen  and  forty-eight  years.  These  were 
all  normal  as  far  as  their  cardiovascular  system  was  concerned  and  none  of 
them  suffered  any  ill  effects  from  the  administration,  despite  the  great 
variations  in  all  readings  occasioned  by  the  gas. 


368 


BLOOD-PRESSURE 


upon  the  concentration  of  the  drug.  The  fall  may  occur 
suddenly  and  be  dangerous  even  after  the  administration 
of  only  a  few  cubic  centimeters  (Fairlie). 


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Fig.  77. — Nitrous  oxid-ether  anesthesia.  (A)  Anesthetic  begun.  (^) 
Nitrous  oxid  anesthesia  complete  and  ether  begun.  (C)  Patient  strugghng. 
(D)  Anesthesia  complete.  {E)  Anesthetic  discontinued.  Note  the  rapid 
rise  from  {A)  to  (£)  incident  to  partial  asphj'xia  of  nitrous  oxid 
and  the  second  rise   (C)  incident  to  muscular  activit\'. 

Chloroform  is  dangerous  in  all  stages  of  its  administra- 
tion, the  greatest  danger  being  at  the  beginning  of  the 
administration.  Struggling  by  the  patient  seems  to  in- 
crease the  bad  effect. 


RELATION  OF  BLOOD-PRESSURE  TO  SURGERY 


369 


Nitrous  Oxid. — Nitrous  oxid,  when  given  alone  in 
sufficient  concentration  to  induce  rapid  anesthesia,  usually 
causes  a  short  elevation  in  blood-pressure,  due  to  the  partial 
asphyxia  induced  (Figs.  74,  75,  and  76).  This  rise  is  not  so 
marked  when  rebreathing  is  allowed  (Guy,  Goodall  and 
Reid)   and  is  almost  entirely  eliminated  when  a  gallon 


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Fig,  78. — Nitrous  oxid-oxygen  anesthesia  by  Dr.  W.  H.  Smith.  Male. 
Aged  forty-five.  Operation  double  herniotomy.  (A)  Preliminary  observa- 
tion, (fi)  Anesthetic  begun.  (C)  Right-side  incision.  (D)  Marked  cyanosis 
relieved  by  increase  in  oxygen  percentage.  (E)  Left  incision  begun.  (F) 
10  per  cent,  ether  vapor  added  for  two  minutes  on  account  of  cyanosis  and 
increased  reflex  action.  (G)  Operation  completed.  Duration  of  anesthetic 
forty -six  minutes.  Relaxation  fair  throughout  except  at  (D)  and  (F). 
Patient's  condition  good  at  all  times  in  spite  of  marked  pallor  and  con- 
tinued profuse  perspiration. 

of  oxygen  is  inhaled  first,  although  the  employment  of 
oxygen  in  this  way  curtails  by  a  few  seconds  the  available 
period  of  anesthesia.  This  is  a  point  of  value  in  cases  of 
essential  hypertension. 

Nitrous  Oxid-Ether  Sequence. — This  anesthetic  causes 
a  gradual  elevation  of  pressure,  until  the  stage  of  complete 

24 


370 


BLOOD-PRESSURE 


anesthesia  is  reached,  when  it  has  practically  the  same  effect 
as  ether  anesthesia  (Fig.  77),  while  the  induction  of  shock 
in  susceptible  cases  seems  to  be  greatly  delayed. 


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Fig.  79. — Ethyl  chlorid  anesthesia.  Male.  Aged  sixteen.  Removal 
of  tumor  of  lower  jaw.  Duration  of  anesthesia  twenty- two  minutes. 
Amount  of  anesthetic  used  12  c.c.  (?).  The  important  feature  of  this 
chart  is  the  profound  effect  of  this  drug  upon  the  pulse  rate,  and  a  de- 
cided initial  rise  in  systolic  pressure,  with  an  exacerbation  incident  to  the 
breaking  of  each  fresh  tube  as  shown  at  A,  B,  C  and  D,  A  rather  irregular 
rise  in  pulse  pressure  incident  to  a  variable  systolic  pressure,  with  a  return 
to  approximately  normal  values  within  a  few  minutes  after  the  end  of  the 
operation.  (A)  Anesthetic  begun,  first  tube.  (B)  Second  tube.  (C)  Third 
tube.     (D)  Fourth  tube.     (E)  Sutures  begun.     (F)  Anesthetic  withdrawn. 

Nitrous  oxid  combined  with  oxygen  produces  a  primary 
rise  in  blood-pressure,  which  immediately  falls  to  normal, 


RELATION    OF   BLOOD-PRESSURE   TO    SURGERY 


371 


as  the  state  of  analgesia  is  reached.  The  proper  control 
of  this  tendency  to  elevation  by  the  oxygen,  allows  the 
pressure  to  be  maintained  at  normal  indefinitely.  Any 
increase  in  the  amount  of  oxygen  or  the  withdrawal  of  the 
nitrous  oxid  usually  causes  a  sudden  and  marked  elevation 
in  blood-pressure,  which  persists  for  from  five  to  fifteen 
minutes  after  the  return  to  consciousness  (Fig.  78). 


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Fig.  80. — Male.  Aged  thirty-eight.  Ethyl  chlorid  experimental  anes- 
thesia— duration  twelve  minutes.  (A)  Anesthesia  begun.  {B)  Patient  feels 
pain.  (C)  Still  feels  pain.  (D)  Another  tube  broken.  {E)  Complete 
anesthesia.  (F)  Anesthetic  removed.  ((?)  Consciousness  returned.  {H) 
Twenty-four  minutes  after  removal  of  anesthetic,  patient  still  has  very 
marked  reduced  pain  sense. 

Ethyl  Chlorid  and  Somnoform. — The  administration  of 
even  3  or  4  c.c.  of  these  anesthetics  has  been  followed  by 
serious  consequences;  5  c.c.  has  been  known  to  produce 
death  and  any  amount  over  this  should  be  considered 


372 


BLOOD-PRESSURE 


dangerous.  Its  effect  is  that  of  powerful  inhibition  of 
both  heart  and  blood-vessel  tone,  causing  a  progressive  fall 
in  blood-pressure.  Ordinarily  the  pulse  is  greatly  elevated 
and  a  dangerous  hypotension  is  usually  accompanied  by 
a  rapid  and  small  pulse.  The  association  of  oxygen  with 
ethyl  chlorid  tends  somewhat  to  prevent  the  hypotension, 


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Fig.  81. — Somnoform  analgesia.  Duration  seventeen  minutes.  Male. 
Aged  twenty.  Report  by  Dr.  C.  S.  Tuttle,  \^A)  Anesthetic  begun.  (J5) 
Second  tube  broken.  (C)  Anesthetic  terminated.  (D)  Oxygen  inhalation 
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(Pression  of  cardiovascular  system  as  shown  by  gradual  fall  of  systolic 
pressure  from  135  mm.  to  105  mm.  in  fourteen  minutes. 

thereby  rendering  the  effect  of  this  anesthetic  less  dangerous 
(Figs.  79,  80  and  81). 

Spinal  Anesthesia. — See  Lumbar  Puncture,  page  358. 

Administration  of  Salvarsan. — The  administration  of 
this  remedy  properly  employed  has  but  slight  effect  upon 
systolic  pressure,  although  a  short  time  afterward  there 


RELATION    OF  BLOOD-PRESSUKE    TO    SURGERY  373 

usually  occurs  a  slight  rise  which  may  persist  for  a  few 
days.  The  effect  of  efficient  treatment  of  the  infection,  par- 
ticularly in  those  showing  aortic  involvement,  is  followed 
by  a  gradual  reduction  in  the  systolic  pressure.  This 
would  suggest  the  value  of  repeated  blood-pressure  observa- 
tions in  demonstrating  the  efficiency  of  specific  treatment 
in  certain  cases. 

Transfusion  Operation. — The  introduction  of  a  volume 
of  blood  into  the  circulation  may,  if  the  transfer  is  ac- 
complished with  undue  rapidity,  cause  a  right-sided 
hypertension.^  This  condition  is  indicated  by  prostration, 
sweating,  slight  nausea,  air  hunger  and  great  uneasiness. 
These  symptoms  can  usually  be  controlled  by  less  rapid 
transfusion  or  temporary  cessation  of  the  flow.  There  is 
no  permanent  alteration  in  pressure  due  to  change  in  blood 
volume. 

Relation  of  Blood  Composition  to  Surgical  Operations. — 
The  data  presented  by  Munzer^  appears  to  demonstrate 
that  many  cases  of  anemia  are  distinguished  by  a  lym- 
phocytosis and  a  hypotension,  and  that  these  cases  stand 
general  anesthesia  badly.  He  warns  against  prolonged 
operations  under  general  anesthesia  in  such  persons.  W. 
J,  Stone^  finds  an  increase  in  pulse  pressure,  in  profound 
anemias,  and  cites  three  cases,  in  which  the  systolic  pressure 
varied  between  120  and  135,  with  pulse  pressures  between 
45  and  65. 

OPHTHALMOLOGIC  DATA 

For  nearly  ten  years  the  value  of  sphygmomanometer 
readings  in  ophthalmology  have  been  receiving  increasing 

1  F.  F.  Simpson,  Jour.  A.  M.  A.,  Sept.  11,  1915,  Ixv,  11,  p.  941. 

2  Medizin.  Klink.,  Dec.  14,  1914,  Ix,  50. 

3  Jour.  A.  M.  A.,  Oct.  4,  1913,  Ixi,  14,  p.  1256. 


I 


374 


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Fig.  82. — Age  about  seventy,  female.  Arteriosclerosis  and  chronic 
articular  rheumatism.  Acute  glaucoma.  (A)  Patient  reported  having  a 
dry  cough  for  two  weeks,  which  continues.  Was  phj^sically  weak,  dyspneic 
and  cyanosed.  Examination  shows  dilated  heart  with  weak  muscle  sounds, 
cyanosis,  edema  of  legs  and  moderate  pulmonary  edema  at  both  bases. 
Response  to  treatment  very  slow  with  several  relapses.  Patient  progressed 
gradually  but  finally  succeeded  in  getting  around  in  the  course  of  two 
months.  (B)  Patient  developed  acute  glaucoma  of  right  eye.  Con- 
fined to  bed.  Treatment  directed  toward  a  reduction  of  systemic  pressure 
by  rest,  sweats  and  purging  with  marked  effect  on  systolic  pressure,  but 
very  little  upon  the  pulse  pressure  as  shown  in  the  chart,  therefore  this 
treatment,  while  benefiting  the  eye  condition,  did  not  actually  relieve  the 
cardiac  overstrain.  (C)  General  condition  good.  Up  and  about.  (D)  Has 
been  taking  digitalis  in  small  doses  irregularly  for  two  months.  Advised 
stopping  digitalis  and  placing  on  routine  treatment. 


RELATION    OF  BLOOD-PRESSTJRE   TO    SURGERY  375 

recognition  and  study,  until  now  we  know  that  there  are 
conditions  that  are  closely  associated  with  high  blood- 
pressure.     These  are  retinal  hemorrhage  and  glaucoma. 

Glaucoma. — Fox  and  Batroff,^  Dunn^  and  Jackson^  all 
dwell  upon  the  importance  of  the  relation  of  elevated 
blood-pressure  to  ocular  glaucoma.  Dunn  states  that  he 
has  never  seen  a  case  of  essential  glaucoma  (Fig.  82)  except 
in  early  youth,  in  which  there  has  not  been  an  elevated 
systolic  pressure,  and  he  quotes  Frinke,  who  found  pressures 
between  140  and  210  mm.  Hg.  in  fourteen  out  of  fifteen 
cases,  and  mentions  a  case  of  a  reduction  in  pressure  from 
200  mm.  Hg.  to  175  and  178  resulted  in  a  favorable  change 
in  an  eye  as  shown  by  a  reduction  in  intra-ocular  tension 
from  T.  3  to  T.  1.  It  is  safe  to  say  that  no  case  can  be 
considered  as  thoroughly  studied  until  the  blood-pressure 
has  been  ascertained. 

Neuroretinitis  and  Retinal  Edema. — ^L.  C.  Peter^  studied 
the  blood-pressure  in  104  cases  of  chronic  interstitial 
nephritis  with  high  pressure,  which  showed  either  retinitis 
or  neuroretinitis;  and  for  purposes  of  comparison,  nine 
cases  of  syphilitic  origin,  with  an  average  systolic  pressure 
of  132,  and  three  cases  of  chronic  parenchymatous  nephritis 
with  a  systolic  pressure  of  132. 

The  average  pressure  in  twenty  of  the  104  cases  of 
retinitis  was  165  mm.  Hg.,  in  fifty-nine  cases  of  neuroretinitis 
it  was  185  mm.  Hg.,  in  three  cases  of  albuminuric  retinitis, 
190  mm.  Hg.,  in  six  cases  of  hemorrhagic  retinitis,  205  mm. 
Hg.  and  in  three  cases  of  papillitis,  225  nun.  Hg.     Thirty- 

1  1908  ref . 

2  Arch.  Ophlh. 

'  Am.  Join-.  Ophlh.,  December,  1909. 
*Penna.  Med.  Jour.,  March,  1911. 


376  BLOOD-PRESSURE 

three  of  the  iiinety-four  kidney  cases  occurred  in  men  and 
sixty-one  in  women.  Peter  concludes  that  arterial  hyper- 
tension is  the  chief  cause  of  these  classes  of  ocular  disease 
and  that  in  them  the  use  of  the  sphygmomanometer  is  clearly 
indicated.  Its  revelations  are  not  only  needful  to  a  proper 
understanding  of  the  pathologic  conditions,  and  suggestive 
in  prognosis  and  treatment,  but  they  will  also  prevent 
blunders,  which  without  this  restraining  influence,  would 
be  inevitable.  According  to  Fox  and  Batroff  the  blood- 
pressure  should  be  carefully  and  systematically  studied  in 
all  eye  cases  past  the  period  of  middle  life. 

Retinal  Hemorrhage  and  Systolic  Pressvire. — The  studies 
of  Fox  and  Batroff^  were  directed  largely  toward  demon- 
strating the  relation  between  retinal  hemorrhages  and  high 
arterial  pressure.  From  a  study  of  100  cases  they  con- 
cluded that  ''the  true  or  exciting  cause  of  these  hemor- 
rhages in  a  very  large  proportion  of  the  cases  is  a  sudden 
transient  or  persistent  abnormal  elevation  of  the  arterial 
pressure."  And  further  that  ''the  blood-pressure  should 
be  carefully  and  frequently  studied  in  this  class  of  ophthal- 
mic cases;  first,  with  a  view  to  determining  the  presence  of 
one  of  the  most  frequent  causal  conditions;  second,  to 
permit  us  to  intelligently  direct  the  treatment.  The 
oculist,  therefore,  often  being  the  first  to  be  consulted, 
should  study  these  patients  with  the  internist,  in  order 
that  the  most  comprehensive  knowledge  possible  should 
be  available  for  the  sufTerer." 

The  summary  of  the  findings  of  Fox  and  Batroff's  series 
of  100  cases  of  hemorrhage  is  as  follows: 

Eighty  per  cent,  occurred  coincidentally  with  other  dis- 

1  Ophthal.  Rec,  October,  1908. 


RELATION  OF  BLOOD-PRESSURE  TO  SURGERY       377 

ease  conditions  in  which  high  blood-pressure  was  the  rule. 
The  majority  of  retinal  hemorrhages  were  found  in  persons 
suffering  from  chronic  interstitial  nephritis,  40  per  cent.; 
the  next  most  common  relation  was  arteriosclerosis,  27 
per  cent. ;  and  as  is  well  known  the  eye-ground  phenomena 
are  often  very  early  to  appear  in  chronic  interstitial  nephri- 
tis and  arteriosclerosis.  Similar  vascular  changes,  associ- 
ated with  high  blood-pressure,  may  be  observed  at  times 
before  these  diseases  can  be  diagnosed  by  other  clinical 
symptoms.  High  systolic  pressure  is  also  a  cause  for  sub- 
conjunctival hemorrhage  and  is  so  closely  associated  with 
glaucoma  that  it  should  be  regarded  as  an  active  factor  in 
the  development  of  this  disease. 

This  author  urges  that,  in  order  not  only  to  prevent,  but 
also  to  treat  rationally  the  more  serious  eye  conditions, 
routine  blood-pressure  studies  should  be  made  in  all  cases 
of  intra-ocular  disease  of  non-traumatic  origin. 

Peter's  conclusions  are  as  follows: 

1.  Arterial  hypertension  is  the  chief  cause  of  the  eye- 
ground  phenoinena  observed  in  chronic  interstitial  nephritis 
and  arteriosclerosis. 

2.  Similar  vascular  changes,  associated  with  high  blood- 
pressure,  may  be  observed  at  times,  before  these  diseases 
are  diagnosed  by  other  clinical  symptoms. 

3.  It  frequently  acts  as  a  cause  for  subconjunctival 
hemorrhage  and  is  so  closely  associated  with  glaucoma  that 
it  should  be  regarded  as  an  active  factor  in  the  develop- 
ment of  the  disease. 

4.  It  probably  will  help  to  explain  the  phenomena  of 
intra-ocular  hemorrhage  after  cataract  extraction. 

5.  In  order  to  prevent  and  to  treat  rationally  the  more 


378 


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Fig.  83. — Male.  Aged  fifty-seven.  Has  never  used  alcohol  or  tobacco  in 
any  form.  Life  has  been  a  hard  one  and  there  have  lately  been  several  severe 
mental  shocks.  Has  long  been  a  sufferer  from  a  chronic  cystitis.  There  is 
some  myocarditis  as  shown  by  irregularity  in  force  and  volume  of  pulse. 
Ophthalmoscopic  examination  of  eye-grounds  shows  nothing  abnormal. 
The  urinalysis  shows  evidence  of  contracted  kidney  and  indicanuria  is  per- 
sistent.    Patient's  symptoms  are  chiefly  gastric  except  for  a  series  of  ocular 


RELATION    OF  BLOOD-PRESSURE    TO    SURGERY  379 

serious  eye  conditions,  routine  blood-pressure  studies 
should  be  made  in  all  cases  of  intra-ocular  disease  not  trau- 
matic in  origin. 

Peter  calls  attention  to  another  group  of  cases  in  which 
hypertension  plays  an  important  role,  namely,  spasm  or 
ataxia  of  the  retinal  artery  or  branches,  which  was 
jBrst  brought  out  by  Zentmayer  in  1906  (Fig.  83). 

In  corneal  ulcers  the  blood-pressure  test  may  give  us  in- 
formation as  to  why  the  treatment  does  not  succeed,  the  ex- 
planation often  being  the  presence  of  chronic  kidney  disease. 

Surgical  Aspect. — As  a  general  rule,  the  higher  the 
systolic  pressure  the  less  favorable  is  it  for  surgical  pro- 
cedures on  the  eye.  A  high  blood-pressure  will  tell  when 
not  to  operate  in  senile  cataract,  and  when  the  danger  of 
hemorrhage  has  been  reduced  by  preliminary  blood-pres- 
sure reducing  measures.  Such  cases  may  have  their  surgical 
prognosis  materially  improved  by  preliminary  medical 
treatment,  directed  toward  amelioration  of  the  excessive 
pressure.     Blood-letting  is  most  beneficial. 

SHOCKi 

In  spite  of  an  immense  volume  of  literatm-e  bearing  on 
the  problem  of  shock,  and  in  spite  of  the  many  theories  as 

attacks  which  have  been  recurring  with  varying  frequency  for  many  years. 
The  ocular  attacks  are  described  as  follows:  An  effect  likened  unto  crisscross 
illumination  or  waves  of  light,  beginning  at  the  left,  in  both  eyes,  and  gradu- 
ally advancing  until  one-half  of  each  retina  is  so  involved.  This  condition 
gradually  fades  and  entirely  disappears  within  ten  minutes.  During  these 
attacks,  if  the  patient  views  a  direct  light,  there  is  marked  tendency  to  the 
development  of  complimentary  colors  in  the  halo  which  appears  upon  the 
affected  side  of  both  retinae.  There  is  no  headache,  dizziness  or  any  other 
symptom.  The  condition  is  explained  upon  the  ground  of  a  persistent 
intestinal  toxemia  producing  a  temporary  disturbance  in  blood-supply  to 
the  arteries  of  the  retinae. 

'  Bibhography  at  end  of  chapter. 


380  BLOOD-PRESSURE 

to  its  cause,  and  the  mechanism  of  its  production,  it  appears 
that  the  situation,  as  far  at  least  as  the  ultimate  solution 
of  the  problem  is  concerned,  remains  clouded. 

Many  theories  have  been  advanced,  since  the  work  of 
Crile  in  1903,  each  of  which  has  both  its  exponents  and 
opponents,  owing  chiefly  to  the  inability  of  any  one  theory 
to  meet  all  the  conditions  involved  in  the  complex  phe- 
nomenon known  as  surgical  shock.  So,  at  the  present 
writing,  it  does  not  appear,  from  the  data  at  hand,  that  the 
final  solution  of  the  problem  has  been  reached. 

Summarily  speaking  we  recognize  five  principal  theories 
as  to  the  origin  of  shock. 

1.  Vasomotor  exhaustion  and  paralysis  (Crile,  Mum- 
mery). 

2.  Cardiac  spasm  and  eventual  failures  (Boise). 

3.  Inhibition  of  the  functions  of  all  the  organs  (Meltzer). 

4.  Acapnia  or  deficiency  of  CO2  in  the  blood  (Yandall 
Henderson) . 

5.  Morphologic  changes  in  the  nervous  system  (Gray 
and  Parsons). 

That  no  one  of  these  is  adequate  is  shown;  1.  By  the 
researches  of  Seelig  and  Joseph  and  of  Seelig  and  Lyon 
who  show  that  the  vasomotor  center  is  not  paralyzed  in 
shock  and  that  the  arteries  are  contracted. 

2.  W.  G.  Porter  and  F.  G.  Mann  have  demonstrated 
that  stimulation  of  a  nerve  trunk,  even  when  prolonged, 
fails  to  cause  its  complete  exhaustion. 

3.  Mann  has  also  shown  that  degenerative  changes  in 
the  central  nervous  system  are  the  result  and  not  the 
cause  of  shock. 

4.  That  inhibition  of  the  function  of  all  organs  has  been 


RELATION    OF   BLOOD-PRESSURE    TO    SURGERY  381 

refuted  by  the  resuscitation  of  shocked,   exsanguinated 
animals  by  transfusion. 

5.  Wainwright  and  also  Short  have  rendered  the  heart- 
spasm  theory  impossible  by  demonstrating  the  excel- 
lent recovery  of  the  heart  in  shock  by  the  operation  of 
transfusion. 

6.  While  Short  demonstrates  that  acapnia  is  not  usually 
present  in  surgical  shock  and  therefore  can  only  be  depended 
on  to  explain  a  few  cases. 

Clinically  shock  may  be  divided  into,  first,  anaphylactic 
shock,  which  is  a  laboratory  phenomenon,  more  of  academic 
than  of  practical  importance.  Second,  toxic  shock  which 
differs  in  no  way  from  surgical  shock,  except  etiologically, 
with  which  its  symptoms  and  disturbances  are  identical. 
Third,  surgical  shock.  This  condition  irrespective  of  its 
etiology  and  the  mechanism  of  its  production,  is  undoubt- 
edly vasomotor,  an  essential  feature  of  which  is  a  radical 
disturbance  in  blood-pressure,  probably  due  to  an  inter- 
ference in  the  normal  distribution  in  the  blood.  Janeway 
and  Jackson  have  shown  experimentallj'^  that  this  disturb- 
ance is  of  such  a  charactei*  that  the  normal  quota  of  blood 
upon  the  arterial  side  of  the  circulation  is  diminished,  and 
that  this  diminution  is  maintained  so  that,  as  a  consequence, 
even  after  the  original  cause  of  the  disturbed  distribution 
of  the  blood,  whether  of  a  mechanical,  toxic  or  inhibitory 
nature,  is  removed,  the  abnormal  distribution  of  the 
blood  upon  the  arterial  side  of  the  circulation  may  not  only 
persist  but,  in  fatal  cases,  continues  until  death. 

Much  experimental  work  tends  to  sustain  the  theory 
that  the  low  pressure  found  in  shock  is  due  to  the  retention 
of  blood  within  the  vessels  on  the  venous  side  of  the 


1 


382  BLOOD-PRESSURE 

circulation,  particularly  of  the  splanchnic  areas,  whereby 
the  volume  of  blood  in  the  arterial  tree  is  reduced  to  such  a 
degree  that  it  mechanically  interferes  with  the  normal 
systole  which  even  the  contracted  arterioles  and  small 
arteries,  that  have  been  demonstrated  to  exist  during 
shock,  fail  to  relieve. 

C.  F.  Mann  explains  the  loss  of  circulatory  fluid  in  a  dif- 
ferent way,  although  the  end-results  are  the  same;  namely, 
a  reduced  systolic  and  a  diminished  pulse  pressure. 

He  believes  ''that  the  clinical  signs  of  shock  which  appear 
after  section  of  the  abdomen  and  exposure  of  the  viscera 
are  due  to  a  loss  of  circulatory  fluid.  This  loss  of  fluid  is 
not  dependent  on  any  primary  impairment  of  the  medullary 
center  and  takes  place  at  a  point  beyond  the  control  of 
the  vasomotor  mechanism.  The  causes  for  this  loss  of 
fluid  are  apparently  the  same  as  those  which  determine 
the  accumulation  of  fluid  in  any  other  irritated  area  and 
produce  the  signs  of  inflammation.  The  nervous  system 
probably  plays  no  greater  part  in  the  former  case  than  in 
the  latter." 

This  diminution  of  the  volume  of  the  circulating  blood 
offers  an  explanation  of  most  of  the  acknowledged  facts. 
It  solves  the  crucial  problem  of  a  low  blood-pressure  with 
constricted  arteries,  vigorous  heart  muscle  and  an  active 
vasomotor  center.  The  changes  in  the  nerve  cells  are  due 
to  the  failure  of  the  proper  blood-supply  and  the  mental 
apathy  is  the  result  of  the  same.  The  small  pulse  and  pale 
skin  are  just  what  we  should  expect  in  such  a  condition. 
The  undoubted  value  of  saline  infusion  into  a  vein  or 
injection  into  the  rectum  also  receives  explanation. 

H.  P.  Fairlie  has  reported  some  practical  conclusions 


RELATION    OF   BLOOD-PRESSURE    TO    SURGERY  383 

drawn  from  a  study  of  the  reaction  of  cases  in  shock  under 
chloroform  and  under  ether. 

The  fall  in  pressure  in  shock  under  ether  is  as  great  as 
the  fall  under  chloroform,  while  the  response  is  slower. 
In  severe  cases  of  shock  at  the  end  of  the  operation,  the 
blood-pressure  shows  a  better  response  under  chloroform 
than  it  does  under  ether. 

After  weighing  all  considerations  Fairlie  suggests  that 
in  the  severe  cases  chloroform  is  the  anesthetic  of  choice, 
but  that  the  anesthesia  should  be  first  induced  by  ether  and 
then  carried  on  by  chloroform.  The  value  of  these  con- 
clusions must  stand  alone,  as  I  have  been  unable  to  find  any 
other  references  on  either  side  of  the  question. 

BIBLIOGRAPHY 

1.  F.  S.  Lee,  Harvey  Lectures,  1905-06,  169. 

2.  W.  G.  Porter,  Am.  Jour.  Physiol.,  1907-08,  xx,  399,  444,  500. 

3.  Seelig  and  Lyon,  Jour.  A.  M.  A.,  Jan,  2,  1909,  lii,  pp.  45,  48. 

4.  Gray  and  Parsons,  Brit.  Med.  Jour.,  April  and  May,  1912. 

5.  Pope,  Calif.  State  Jour.  Med.,  1913,  xi,  499. 

6.  H.  P.  Fairlie,  Lancet,  Feb.  28,  1914,  i,  4722. 

7.  Janeway  and  Ewing.  Ann.  Surg.,  1914,  lix,  158. 

8.  F.  G.  Mann,  Johns  Hopkins  Bull,  1914,  xxiv,  205. 

9.  Seelig,  Surg.  Gyn.  and  Obstet.,  1914,  xviii,  Abstra.,  p.    117. 

10.  Short,  Brit.  Jour.  Surg.,  1914,  i,  114. 

11.  Seelig  and  Joseph,  Proc.  Soc.  Ezper.  Biol,  and  Med.,  1914,  xii,  49. 

12.  Wainwright,  Penna.  Med.  Jour.,  December,  1914,  xviii,  3. 

13.  C.  F.  Mann,  Surg.  Gijn.  and  Obstet.,  1915,  xxi,  430. 

14.  Mann,  Surg.  Gyn.  and  Obstet.,  1915,  xxi,  430. 

15.  Morrison  and  Hooker,  Amer.  Jour.  Physiol.,  1915,  April. 

16.  H.  H.  Janeway  and  H.  C.  Jackson,  Proc.  Soc.  Exper.  Biol,  and  Med., 
1914  and  1915,  xii,  193. 


CHAPTER  XXI 
THE  BLOOD-PRESSURE  TEST  IN  OBSTETRICS 

The  universal  employment  of  the  sphygmomanometer 
and  the  routine  study  of  normal  and  pathologic  cases  of 
pregnancy,  during  the  past  decade,  have  established  a 
number  of  working  rules  which  now  serve  as  guides  in  diag- 
nosis and  prognosis,  so  that  the  sphygmomanometer  now 
ranks  with  urinalysis  in  the  examination  of  the  pregnant. 

In  the  blood-pressure  test  we  have  a  most  valuable  means 
of  detecting  early  toxemias,  which  often  lead  to  the  eclamp- 
tic state.  Abnormal  blood-pressure  readings  are  one  of  the 
earliest  indications  of  a  departure  from  normal  metabolism 
in  the  pregnant.  This  change  may  be  evident  before  the 
development  of  any  physical  signs,  or  of  any  noticeable 
change  in  the  urine.  From  a  pathologic  standpoint,  it  is 
evident  that  the  close  relation  between  the  kidney  and 
blood-pressure  should  be  a  valuable  guide  during  this  con- 
dition, since  alterations  in  metabolism,  the  retention  of 
waste  products  and  the  development  of  special  toxins  in 
the  blood  usually  show  themselves  in  a  gradually  rising 
blood-pressure,  the  one  exception  to  this  rule  being  those 
toxemias  of  hepatic  origin  in  which  the  blood-pressure 
usually  is  not  elevated  (see  page  392) .  These  cases  are,  how- 
ever, so  few  that  they  do  not  detract  from  the  value  and 
importance  of  the  blood-pressure  examination. 

Routine  blood-pressure  observations  should  be  made 
a  part  of    the   periodic   examination   during  pregnancy. 

384 


THE   BLOOD-PRESSURE    TEST    IN    OBSTETRICS  385 

The  intervals  between  the  tests  should  be  shortened  as  the 
pregnancy  advances,  and,  should  abnormal  symptoms 
appear  at  more  frequent  intervals.  The  test  should  not  be 
omitted  during  the  puerperium,  as  at  this  time  the  patient 
may  develop  serious  toxemia  and  eclamptic  attacks. 

Pregnant  patients  should  have  the  blood-pressure  test 
applied  at  least  as  frequently  as  the  urine  is  examined. 
It  would  be  advisable  to  apply  the  sphygmomanometer  as 
often  as  practicable.  So  employed,  and  with  the  records 
properly  charted,  blood-pressure  tests  may  furnish  a  far 
more  adequate  indication  of  the  seriousness  of  a  pregnancy 
nephritis  and  the  urgency  of  inducing  labor,  than  the  usual 
urinalysis. 

THE  NORMAL  BLOOD-PRESSURE  DURING  PREGNANCY 

Most  observers  agree  that  the  average  systolic  blood- 
pressure  during  most  of  the  period  of  pregnancy  is  in  the 
neighborhood  of  120.  John  C.  Hirst^  in  the  study  of  100 
cases  obtained  a  general  average  systolic  pressure  of  118. 

H.  C.  Bailey-  arrived  at  the  same  average.  While  these 
same  authorities  look  upon  a  persistent  pressure  of  over  145 
with  suspicion,  Arthur  J.  Benedict^  believes  that  a  pres- 
sure of  over  125  in  pregnancy  is  abnormal  and  indicates 
toxemia. 

I  have  private  records  of  205  observations  made  upon 
thirty-four  cases  of  normal  pregnancy,  in  which  the  diastolic 
and  pulse  pressure  readings  as  well  as  the  systolic  were 
made  simultaneously,  with  complete  urinalyses.  The 
following  is  a  summary  of  the  results  obtained: 

1  N.  Y.  Med.  Jour.,  June  11,  1910,  p.  204. 

'^  Surg.  Gyn.  and  Obsiet.,  Vol.  xiii,  5,  1911,  p.  485, 

3  Brit.  Med.  Jour.,  Dec.  3,  1910. 
25 


386  BLOOD-PRESSURE 

Normal 

Number  of  cases 34 

Number  of  observations 205 

Average  systolic 117.5  mm.  Hg. 

Highest  systolic 140.0  mm.  Hg.  (4  cases) 

Lowest  systolic 90.0  mm.  Hg.  (1  case) 

Average  pulse  pressure 38.5  mm.  Hg. 

Highest  pulse  pressure 65.0  mm.  Hg.  (1  case) 

Lowest  pulse  pressure 25.0  mm.  Hg.  (2  cases) 

Average  diastolic 79.0  mm.  Hg. 

Highest  diastolic 95.0  mm.  Hg.  (1  case) 

Lowest  diastolic 65.0  mm.  Hg.  (2  cases) 

Average  pulse  rate 85.1 

Highest  pulse  rate 140.0  (1  case) 

Lowest  pulse  rate 72.0  (8  cases) 

The  following  is  a  summary  of  124  urinalyses  made  upon 
the  same  group: 

Thirty-four  normal  cases. 

One  hundred  and  twenty-four  examinations. 

Eight  or  23.5  per  cent,  (of  cases)  showed  no  albumin  at  any  time. 

Sixteen  or  47.9  per  cent,  showed  albumin  during  first  five  months. 

Sixteen  or  47.9  per  cent,  showed  albumin  during  last  four  months. 

The  albuminuria  bore  no  definite  relation  to  the  pressure  reading  or  the 
period  of  gestation. 

The  specific  gravity  ran  from  1005  to  1036 — average  1018. 

Twenty-one  or  61.7  per  cent,  showed  at  some  time  casts  or  cylindroids 
in  smaU  numbers.  Three  showed  granular  casts  which  had  apparently  no 
significance.  Four  cases  which  showed  indican  had  an  average  systolic 
pressure  of  105  mm. 

The  opinion  is  generally  held  that  there  is  but  slight 
change  in  the  systolic  pressure  until  the  later  months  of 
pregnancy  and  that  then  a  slight  rise  occurs. 

In  four  abnormal  cases  under  my  care  involving  six 
pregnancies,  the  average  systolic  pressure  was  158,  while 
the  urine  ranged  from  a  mere  trace  to  a  solid  mass  of  albu- 
min in  the  tube  after  boiling.  The  microscope  showed  all 
varieties  of  abnormal  morphologic  elements. 

Naturally  the  individual  readings  must  vary  greatly 
within  certain  limits,  as  these  patients  are  subject  to  the 


THE   BLOOD-PRESSURE    TEST    IN    OBSTETRICS  387 

same  influences  which  affect  the  reading  in  other  indi- 
viduals, SO  that  rapid  variations  are  probably  insignificant 
unless  they  exceed  30  mm.  above  the  average  and  remain 
persistently  at  or  above  the  high  normal  limit. 

EFFECT  OF  LABOR  ON  BLOOD-PRESSURE 

During  the  first  stage  of  labor,  at  the  recurrence  of  pains 
there  is  a  marked  rise  in  pressure  which  falls  in  the  intervals, 
but  usually  during  the  first  and  second  stages  the  level 
remains  at  from  140  to  150  even  between  pains  (Bailey). 

Hirst  had  noted  that  a  fall  of  pressure  coincides  with 
rupture  of  the  membranes,  sometimes  amounting  to  50  or 
more  millimeters,  usually  accompanied  by  marked  relief 
from  headache  and  epigastric  symptoms.  This  is  tem- 
porary, as  the  pressure  gradually  rises  as  labor  continues. 
There  is  a  second  fall  of  60  to  90  mm.  immediately  after  child- 
birth, which  is  also  temporary,  the  pressure  soon  returning 
almost  to  the  level  attained  before  birth.  Profuse  hemor- 
rhage or  the  supervention  of  exhaustion  will  interfere  with 
this  rise,  the  degree  of  reduction  in  pressure  indicating  the 
seriousness  of  these  complications.  Obstetric  operations, 
according  to  Cook  and  Briggs,^  which  involve  the  intro- 
duction of  the  hand  into  the  vagina  or  uterus,  and  instru- 
mental deliveries,  cause  a  sharp  reflex  rise  which  has  been 
known  to  result  in  rupture  of  a  cerebral  vessel. 

COMPLICATIONS  AFFECTING  BLOOD -PRESSURE  DURING 
PREGNANCY 

Albumintiria. — Albumin  in  small  quantities  appearing 
in  the  urine  during  pregnancy  cannot  be  considered  patho- 
logic, as  in  a  large  percentage  of  cases  it  appears  from  time 

^  Johns  Hopkins  Hosp.  Rep.,  1903,  Vol.  xi,  451. 


388 


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Fig.  84. — Aged  twenty-five.  Two  pregnancies*  the  first  toxic,  the 
second  not. 

At  (A)  five  months  pregnant  (Marcli,  1911).     Normal  to  this  date. 

At  (B)  beginning  development  of  edema,  headaches,  albuminuria  un- 
restrained by  dietetic  regulations  between  (B)  and  (C). 

At  (C)  hot-packs  begun,  with  slight  reduction  in  sj'stolic  pressure  but 
failure  to  relieve  cardiac  over-action  as  shown  by  the  continued  elevation 
of  pulse  pressure. 

(D)  Gradual  failure  of  eliminativc  measures.  Sj'mptoms  more  marked 
but  not  considered  urgent. 

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(F)  Delivered  without  serious  complications. 

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edema,  dyspnea,  with  albumin  and  casts  in  the  urine. 

(A^)  Between  five  and  six  months  pregnant  (April,  1913)  with  marked 
signs  of  kidney  failure.     Dietetic  and  eliminative  measures  instituted. 


THE   BLOOD-PRESSURE    TEST    IN    OBSTETRICS  389 

to  time  and  seems  of  itself  to  have  no  relativity  to  the  sub- 
sequent course  of  the  case.^  In  a  series  of  thirty-four 
normal  cases  which  I  have  recorded,  albumin  appeared  in 
sixty-two  examinations  of  50  per  cent.  The  combination 
of  traces  of  albumin  with  a  rising  systolic  pressure  will  give 
the  obstetrician  pause,  and  a  rising  pressure  plus  albumin 
which  fails  to  respond  to  treatment  is  an  indication  for  the 
forced  termination  of  pregnancy^  (Fig.  84). 

Pernicious  Vomiting. — -Donaldson's^  observations  lead 
to  the  belief  that,  while  this  condition  may  demand  the 
induction  of  labor,  the  blood-pressure  is  not  elevated ;  which 
plainly  suggests  that  the  toxemia  in  these  cases  differs 
from  that  occurring  in  eclamptics. 

Glycosuria. — Donaldson  reports  nothing  abnormal  in 
the  blood-pressure  readings  in  glycosuria,  which  coincides 
with  my  own  experience  and  is  shown  in  the  accompanying 
chart  (Fig.  85). 

Hemorrhage. — Wallich^  considers  that  elevation  of  pres- 
sure during  pregnancy  tends  to  hemorrhage  and  that  this 
accounts  for  the  hemorrhagic  lesions  so  common  in  eclamp- 
sia. On  the  other  hand,  estimation  of  blood  pressure  is 
important  in  suspected  hemorrhage  as  in  cases  of  ectopic 

(£')  All  symptoms  subsided.  Patient  on  rigid  diet  and  hygiene.  Condi- 
tion satisfactory.     Urine  shows  only  slight  evidence  of  renal  irritation. 

(C^)  Delivered  at  term. 

(D^)  Two  months  after  delivery.  Condition  excellent.  Urine  practic- 
ally normal,  no  evidence  of  kidney  insufficiency. 

Note,  January,  1916,  patient  has  not  been  pregnant  again,  has  enjoyed 
good  health  and  shows  no  evidence  of  kidney  involvement. 

1  Franklin  S.  Newall,  Jour.  A.  M.  A.,  Jan.  30,  1915,  Ixiv,  5. 

2  M.  Donaldson,  Jour.  Obstet.  and  Gyn.,  London,  September,  1913,  xxiv, 
3;  and  J.  D.  Lippincott,  Jour.  A.  M.  A.,  Aug.  10,  1912,  hx,  6. 

^  Loc.  cit. 

*  V.  Wallich,  Annal.  deGynae.  et  d'Obslet.,  November,  1913,  xxxix,  No.  11. 


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Fia.  85. — Female.  Aged  thirty-two.  Primipara.  Glycosuria.  Albumin 
appearing  the  third  month  (A)  and  sugar  was  first  noted  the  fifth  month  (5) 
and  reached  IJ-^  per  cent.  Dietetic  measures  were  followed  by  its  dis- 
appearance at  (C)  after  which  it  did  not  return.  Patient  was  delivered 
Sept.  24  (D)  of  a  normal  baby  and  had  an  uneventful  convalescence.  Im- 
portant points  in  this  case  appeared  to  be  a  rather  marked  depression  of 
systolic  pressure  during  the  period  of  glycosuria,  its  rapid  disappearance 
and  continued  absence  up  to  and  after  delivery.  In  spite  of  the  rise  in 
systolic  pressure  to  150  this  patient  had  at  no  time  showed  signs  of  kidney 
insufficiency  or  toxemia. 


THE   BLOOD-PRESSURE   TEST   IN    OBSTETRICS  391 

gestation  and  other  surgical  complications,  as  a  sudden  and 
continued  drop  accompanied  by  a  rising  pulse  rate  is  sig- 
nificant of  persistent  hemorrhage.  If,  after  noting  these 
significant  changes,  they  are,  by  subsequent  observation, 
found  to  be  arrested  or  to  have  become  reversed,  it  is  safe 
to  infer  that  the  hemorrhage  has  ceased.  P.  Ballard^ 
in  discussing  the  significance  of  pressure  changes  to  hemor- 
rhage states  that  the  systolic  pressure  in  hemorrhage  may 
vary  within  a  wide  range,  but  that  a  diastolic  pressure  of 
50  mm.  appears  to  be  the  lowest  point  at  which  the  heart  is 
able  to  keep  the  blood  circulating. 

Low  Pressure  at  Term. — Franklin  S.  NewalP  considers 
that  an  abnormally  low  pressure  at  term  (100  or  less)  in 
the  absence  of  toxemia,  suggests  that  the  patient  is  in 
poor  condition  and  is  likely  to  react  unduly  to  the  strain 
of  labor,  so  that  under  these  conditions  every  effort  should 
be  made  to  avoid  excessive  strain,  suffering  and  shock. 

Toxemia  and  Eclampsia. — John  Cooke  Hirst^  states  that 
the  earliest  and  most  constant  sign  of  toxemia  in  the  latter 
half  of  pregnancy  is  a  high  and  constantly  rising  blood- 
pressure  (Fig.  86),  and  this  symptom  precedes  albuminuria 
and  all  the  constitutional  signs  of  an  impending  eclamptic 
attack. 

This  most  serious  and  often  fatal  complication  of  preg- 
nancy and  the  puerperium  is  recognized  as  the  most  fruit- 
ful cause  of  elevated  systolic  pressure,  although  a  high 
blood-pressure  is  not  the  invariable  accompaniment  of  this 
condition.     J.  C.  Hirst  states :^  ''cases  are  seen  undoubtedly 

1  Arch.  Mens.  d'Obstet.  et  de  Gynae.,  December,  1914,  iii,  12. 

^  Jour.  A.  M.  A.,  Jan.  30,   1915,  Ixiv,  5,  p.  393, 

3  A^.  Y.  Med.  Jour.,  June  11,  1910. 

*  Penna.  Med.  Jour.,  xviii,  8,  1915,  p.  650. 


392 


BLOOD-PRESSURE 


toxic,  even  in  eclampsia,  with  a  pressure  of  130  or  lower." 
These  are  probably  of  liver  origin,  and  are  usually  more 
serious  than  those  of  nephritic  origin.  The  blood-pressure 
test  may  serve  as  a  basis  for  differentiation. 

BLOOD  PRESSURE  CHART 


IT  NO.,     li  ...  1  . 


CHART  NO 
NAME 

ADDRESS ■ ■  . 
OCCUPATIOiy  .  .  .• 

DIAGNOSI&^.mUyvi.'XAA' 


AGE  ■  .X^.  . 
COLOR  .VY. 
SEX  .J.  ...  . 
PHYSICIAN. 


Fig.  86. — May  2,  case  showed  albumin,  scanty  urine,  headaches  and  dizzi- 
ness, symptoms  relieved  by  hot  pack  and  purgation  at  irregularly  repeated 
intervals.  Premature  induction  of  labor  advised  but  declined.  Normal 
delivery  on  August  9.  Treatment  controlled  subjective  symptoms,  but  did 
not  much  affect  the  tendency  to  a  rising  blood-pressure. 


The  prevailing  opinion  is  that  eclampsia  is  usually  ac- 
companied by  a  pressure  of  over  200  mm.  Hg.^ 

Two  cases  have  been  reported  by  Hirst  with  pressures  of 
400  to  420  and,  surprising  to  record,  they  both  got  well, 
so  that  extremely  high  pressures  are  not  necessarily  fatal, 


^  J.  O.  Evans,  A'^.  TI^'.  Medicine,  June,  1912,  iv,  6,  p.  183,  and  H.  Vaquez, 
La  Semaine  Medicale,  1907,  li,  p.  121,  and  Bailey,  loc.  cit. 


THE   BliOOU-PRESSURE    TEST    IN'    OBSTETRICS  393 

although  cUnically  the  lower  the  pressure  in  actual  eclamp- 
sia, the  more  favorable  the  prognosis. 

If  abnormally  high  pressure  persists  in  the  third  stage, 
or  there  is  little  or  none  of  the  normal  decline,  measures 
for  relief  must  be  instituted  almost  as  urgently  as  if  the 
seizures  were  present. 

T.  M.  Green  ^  conveniently  divides  toxemia  of  pregnancy 
into  three  divisions: 

First,  moderate  increase  in  blood-pressure. 

Second,  marked  increase  in  blood-pressure. 

Third,  extreme  increase  of  blood-pressure. 

To  these  may  be  added  the  fourth,  which  is  suggested 
by  the  studies  of  Hirst  and  of  Baily,  namely:  extreme 
eclamptic  condition  in  which  the  blood-pressure  may  be  low. 

In  the  first  two,  symptoms  disappear  and  blood-pressure 
falls  after  delivery.  In  the  third  and  fourth,  blood-pres- 
sure continues  abnormal,  and  the  disease  usually  progresses 
to  a  rapidly  fatal  termination. 

To  summarize  our  present  knowledge  of  the  relation  of 
blood-pressure  findings,  it  is  believed  that: 

First,  the  normal  blood-pressure  in  healthy  pregnant 
women  will  average  close  to  118  mm.  A  slight  increase 
over  these  figures  but  below  150  mm.,  is  to  be  expected  in 
the  last  month  of  pregnancy. 

Second,  blood-pressure  in  toxemia  in  the  first  half  of 
pregnancy,  associated  with  pernicious  vomiting,  is  usually 
low. 

Third,  blood-pressure  in  the  latter  half  of  pregnancy, 
associated  with  albuminuria  and  eclampsia,  is  invariably 
high. 

^  Boston  Med.  and  Surg.  Jour.,  Apr.  28,  1910. 


394 


BLOOD-PRESSURE 


Fourth,  a  high  and  rising  blood-pressure  is  an  invariable 
and  very  often  the  earliest  sign  of  toxemia  in  the  latter 
half  of  pregnancy. 

Fifth,  the  actual  height  of  the  pressure  is  not  of  itself 
necessarily  an  indication  of  the  gravity  of  the  prognosis. 

BLOOD  PRESSURE  CHART 

CHAtrr  NO. . . .  .^. 

ADDRESS . . 
OCCUPATIO, 


Fig.  87. — Term  calculated  to  March  30,  labor  induced  March  9.  Feb- 
ruary 5,  ankles  edematous,  marked  gastric  irritation,  large  amount  of 
albumin  in  urine.  This  condition  not  relieved  by  treatment.  March  7, 
urine  boiled  nearly  solid.  March  9,  labor  induced;  March  10,  delivered; 
April  3,  albumin  absent,  patient  normal. 

Sixth,  cases  of  eclampsia  which  recover,  usually  show  a 
rapid  fall  of  pressure  after  delivery,  while  the  high-pres- 
sure cases  which  eventually  die  have  a  persistently  high 
pressure. 

Seventh,  usually  in  eclampsia,  the  pressure  remains  high 


THE   BLOOD-PRESSURE    TEST    IN    OBSTETRICS  395 

for  forty-eight  hours  after  the  birth,  then  begins  to  subside 
and  reaches  the  normal  of  from  118  to  124  mm.  in  from 
seven  to  ten  days  after  deUvery. 

Eighth,  upon  the  rupture  of  the  membranes,  in  toxic 
cases,  there  is  an  immediate  fall  of  pressure  of  from  60  to 
90  mm.  This  fall  is  temporary  only,  but  is  attended  with 
marked  relief  in  the  headache  and  epigastric  pain  these 
patients  so  frequently  complain  of.  However,  after  some 
hours  the  pressure  returns  toward  its  original  level. 

Ninth,  there  is  a  second  fall  of  from  60  to  90  mm.  after 
the  child  is  born.  This  again  is  only  temporary,  as  in  from 
fifteen  to  thirty  minutes,  if  a  patient  has  not  bled  profusely, 
the  pressure  returns  to  about  its  level  before  birth. 

Tenth,  as  far  as  it  is  possible  to  lay  down  any  rules  in 
these  cases  we  may  say  that  a  blood-pressure  of  below  125 
mm.  could  be  disregarded,  a  pressure  of  from  125  to  150 
mm.  needs  careful  watching  and  moderate  eliminative 
treatment,  and  that  a  pressure  of  over  150  mm.  needs  usu- 
ally active  eliminative  treatment,  and  will  in  all  probability, 
especially  if  it  shows  a  tendency  to  climb  higher,  require  the 
induction  of  premature  labor  (Fig.  87). 

EFFECTS  OF  DRUGS  UPON  BLOOD-PRESSURE  DURING 
PREGNANCY  AND  LABOR 

Ergot  has  apparently  no  effect  on  either  normal  or 
abnormal  pressures. 

Pituitrin  produces  a  rapid  temporary  elevation  of  from 
25  to  40  mm.  and  occasionally  a  violent  rise  in  pressure, 
there  are  exceptions  where  it  has  no  effect.  The  action  is 
most  rapid  when  administered  intravenously.  This  sudden 
elevation  may  be  harmful  in  toxemic  cases  and  those  with 


39G  BLOOD-PRESSURE 

cardiorenal    complications.     The    elevation    persists    for 
from  thirty  to  forty  minutes  and  is  often  followed  by  a 

sudden  fall  to  below  normal.^ 

Scopolamin  and  Morphin  Narcosis. — Joseph  L.  Baer^ 
reports  an  average  fall  of  5  mm.  in  a  clinical  study  of  sixty 
cases. 

Chlorofonn. — This  anesthetic  is  considered  dangerous 
by  Whipple,^  both  because  of  its  blood-pressure-reducing 
propensity  and  because  of  the  frequency  of  subsequent 
liver  necrosis  following  its  use,  which  would  tend  to  favor 
toxemia. 

1  S.  S.  Arbuck  and  A.  J.  Rongy,  N.  Y.  Med.  Jour.,  May  2,  1914,  p.  878. 

2  Jour.  A.  M.  A.,  Ixiv,  21,  May  22,  1915,  p.  1723. 

3  G.  H.  Whipple,  Jour.  Exp.  Med.,  Mar.  1,  1912. 


CHAPTER  XXII 

BLOOD-PRESSURE  ESTIMATIONS  IN  PHYSICAL  EXAMI- 
NATIONS FOR  LIFE  INSURANCE 

Prior  to  1907,  when  the  pubhcation  of  Janeway's  book 
on  blood-pressure  gave  a  new  impetus  to  blood-pressure 
studies,  little  or  no  use  was  made  of  the  sphygmomanom- 
eter in  the  examination  of  applicants  for  life  insurance. 
In  the  following  year  (1908)  the  present  author  undertook 
a  statistical  study  of  this  subject  with  a  view  to  deter- 
mining the  attitude  of  life  insurance  companies  toward  the 
blood-pressure  test.  A  circular  letter  containing  a  series  of 
questions  was  addressed  to  forty-six  medical  directors, 
and  a  summary  of  these  replies  embodied  in  a  paper  read 
before  the  American  Association  of  Life  Insurance  Ex- 
aminers at  their  Atlantic  City  session  in  June,  1909.^ 
While  pursuing  this  investigation,  I  had  an  opportunity  of 
addressing  the  Philadelphia  Medical  Examiners'  Associa- 
tion on  March  2,  1909,  upon  this  same  subject^  at  which 
time  I  said,  ''Recent  increase  in  clinical  data,  which  is  the 
result  of  finer  methods  of  observation  (of  blood-pressure), 
demand  greater  recognition  bj^  the  practicing  physician  and 
the  medical  examiner"  and  further,  ''the  sphygmomanom- 
eter is  a  valuable  aid  in  determining  arterial  tension,  and 
in  differentiating  diseases  of  the  cardiovascular  system." 

The  replies  of  thirty-two  medical  directors,  to  this  cir- 
cular letter,  developed  the  interesting  fact  that  at  that 

1  N.  Y.  Med.  Jour.,  July  23,  1910. 

2  N.  Y.  Med.  Jour.,  May  22,  1909. 

397 


398  BLOOD-PRESSURE 

time  no  insurance  company  of  any  note  employed  the  blood- 
pressure  test  in  all  examinations,  although  67  per  cent,  made 
partial  use  of  it  and  found  it  valuable  in  special  conditions 
where  impairment  was  suspected,  either  because  of  infor- 
mation previously  acquired,  or  in  overweights,  in  those  of 
special  occupations,  and  in  those  in  which  the  result  of 
part  of  the  examination  suggested  the  presence  of  an  ele- 
vated systolic  pressure  in  connection  with  cardiac,  vascular 
or  kidney  lesions.  The  article  concluded  with  the  follow- 
ing: "Bearing  in  mind  that  25}io  per  cent,  of  insured  risks 
in  one  company — were  due  directly  or  indirectly  to  a  patho- 
logic increase  in  blood-pressure,  I  submit  .  .  .  ,  in  the  sphyg- 
momanometer we  have  a  ready  and  accurate  means  of 
determining  a  greater  number  of  such  cases,  than  is  possible 
by  the  means  heretofore  at  the  disposal  of  the  examiner  for 
life  insurance. 

"This  alone,  should  be  sufficient  argument  for  the 
universal  adoption  of  this  test,  which  would  result  in  much 
financial  saving  to  the  life  insurance  companies." 

Following  this  lead  J.  W.  Fisher,  in  1911,^  after  employing 
the  test  for  a  couple  of  years  stated  that:  "No  practitioner 
of  medicine  should  be  without  a  sphygmomanometer. 
He  has  in  this  instrument  a  most  valuable  aid  to  diagnosis. 
The  sphygmomanometer  is  indispensable  in  life  insurance 
examinations,  and  the  time  is  not  far  distant  when  all 
progressive  life  insurance  companies  will  require  its  use  in 
all  examinations  of  applicants  for  life  insurance,"  prac- 
tically a  repetition  of  the  author's  prediction  of  two  years 
before. 

^  Quotation  taken  from  article  by  same  author,  Jour.  A.  M.  A.,  Nov.  14, 
1914,  Ixiii,  No.  20. 


BLOOD-PRESSURE    IN    LIFE    INSURANCE  399 

A  general  application  of  this  fact  has  been  so  rapid  that 
to-day,  with  possibly  one  or  two  exceptions,  the  blood- 
pressure  test  is  employed  by  all  American  life  insurance 
companies  and  by  the  majority  of  those  abroad.  Indeed 
the  medical  directors  are  now  agitating  in  favor  of  the  dias- 
tolic determination  as  well  (see  Chapter  V,  page  89,  for 
importance  of  diastolic  blood-pressure  tests). 

A  recent  and  able  argument  in  the  same  cause,  by  J.  S. 
Lankford,  appears  in  the  May  23,  1914,  issue  of  the  Medical 
Record  (Vol.  85,  No.  21). 

VALUE  OF  THE  TEST  IN  LIFE  INSURANCE 

By  this  test  we  may  very  early  detect  signs  of  beginning 
pathologic  change  in  the  cardiovascular  system  and  in  the 
kidneys,  often  before  there  is  any  demonstrable  evidence  of 
departure  from  normal  either  in  the  physical  signs,  personal 
history  or  urine.  This  is  chiefly  because  the  apparent 
character  of  the  pulse,  and  the  examination  of  the  super- 
ficial vessels,  does  not  always  portray  the  actual  condition 
of  the  general  arterial  tree  or  the  degree  of  arterial  tension. 

Clinicians  are  agreed  that  tactile  estimation  of  blood- 
pressure  is  most  unsatisfactory,  and  in  many  cases  unre- 
liable and  often  misleading.  Even  the  most  experienced 
have  been  unconsciously  led  into  grave  error  by  depending 
upon  tactile  sensations  when  the  sphygmomanometer 
could  have  been  employed. 

To  quote  from  Wm.  Russell  we  find  the  following  very 
significant  statement:  ^'I  must,  however,  again  add  a 
warning  note  to  the  effect  that  feeling  the  radial  pulse  is 
not  always  a  reliable  guide  as  to  what  the  blood-pressure 
will  read.     I  have  two  such  cases  under  observation,  the 


400  BLOOD-PRESSURE 

radial  being  neither  hard  nor  incompressible,  and  yet  in 
both  there  is  a  steady  reading  of  over  200  mm.  Hg." 

Many  times  we  may  feel  a  soft  and  compressible  radial 
where  there  exists  marked  sclerosis  of  the  aorta  and  of  the 
splanchnic  area.  Here  the  blood-pressure  test  alone  reveals 
the  true  situation.  In  other  instances  the  reading  of  the 
sphygmomanometer  may  explain  the  significance  of  an 
apparently  simple  headache,  a  mild  attack  of  indigestion, 
or  transitory  attacks  of  vertigo  in  an  apparently  healthy 
individual,  by  demonstrating  that  these  cases  have  suffered 
from  a  long-continued  toxemia,  which  has  resulted  in  an 
unsuspected  pathologic  change  in  the  cerebral  or  general 
arterial  system. 

From  the  clinical  standpoint,  it  is  now  well  recognized 
that  such  pathologic  changes  may  be  present  in  the  cardio- 
vascular and  renal  systems,  long  before  any  subjective 
symptoms  are  complained  of  by  the  individual,  or  if  any 
complaint  is  made,  the  symptoms  are  usually  attributed  to 
some  trivial  cause. 

John  B.  McAlister^  states  that  insurance  statistics  of 
1247  cases  of  all  ages,  in  which  the  pressure  was  150  mm. 
or  over  showed  a  mortality  of  two  and  one-half  times  that  of 
the  general  mortality  for  the  same  period.  Of  these,  891 
or  more  than  three-fifths,  had  no  impairment  recorded  other 
than  the  high  pressure.  The  important  bearing  of  this  upon 
the  character  of  insurance  risks  is  shown  by  Thayer  and 
Brush,  who  after  a  critical  study  of  3894  persons  at  Johns 
Hopkins  Hospital  draw  the  following  conclusion:  "it  seems 
to  us  that  there  can  be  little  doubt  that  the  main  etiologic 
factor  in  the  development  of  hyperplastic  thickening  of  the 

1  Med.  Council,  July,  1914. 


BLOOD-PRESSURE    IN    LIFE    INSURANCE  401 

intima,  which  constitutes  so  important  an  element  in 
arteriosclerosis,  is  overstrain  of  the  vascular  wall  from  con- 
tinued or  intermittent  high  tension,  whatever  the  ultimate 
cause  may  be." 

Formula  to  Estimate  Normal  Pressure. — To  furnish  a 
ready  method  of  determining  the  average  normal  blood- 
pressure  at  a  given  age,  the  author  has  suggested  a  formula, 
based  upon  a  large  number  of  observations  of  his  own  and 
of  others,  which  can  be  universally  applied.  The  average 
obtained  by  the  formula  agrees  closely  with  the  experience 
of  most  observers,  and  since  its  first  publication  in  1910,^ 
it  has  been  extensively  quoted  and  is  now  emplo^'-ed  by 
at  least  one  insurance  company  (The  Provident  Life  and 
Trust  Company,  Philadelphia).  As  originally  suggested, 
it  was  as  follows:  ''Consider  the  average  normal  systohc 
blood-pressure  in  the  male  at  age  twenty  to  be  120  mm.  of 
Hg. ;  for  each  year  of  life  thereafter  14.  mm.  to  120."  Later 
it  seemed  advisable  to  eliminate  the  fraction,  and  this  was 
done  by  changing  the  phraseology  to  read  as  follows: 
"Consider  the  normal  average  systolic  blood-pressure  of  a 
male,  age  twenty  to  be  120  mm.,  then  add  1  mm.  to  every 
additional  two  years  of  life."  In  both  the  formulas  the 
result  is  the  same,  thus  at  the  age  thirty  the  normal  average 
systolic  blood-pressure  would  be  125,  at  sixty,  140  mm.,  etc. 
It  is  sufficiently  established  to  pass  without  question  that 
the  normal  average  blood-pressure  for  females  at  the  same 
ages  is  approximately  10  mm.  less  than  for  the  male. 

Permissible  Variations. — It  is  not  sufficient  to  establish 
a  normal  average  with  which  to  rate  the  risk  but  it  is 

^"The  Sphygmomanometer  and  its  Practical  Application,"  PiUing  Co., 
Philadelphia,  1910. 

26 


402  BLOOD-PRESSURE 

necessary  also  to  determine  what  variations  above  and 
below  this  shall  be  accepted  as  normal.  Unfortunately, 
with  the  evidence  at  hand  this  question  cannot  be  defi- 
nitely   answered,    for    existing    statistics    do    not    agree. 

Janeway  regards  with  suspicion  any  systolic  pressure 
which  remains,  before  middle  life,  persistently  above  145 
mm.  and  places  the  maximum  safe  level  at  16C  in  later  years. 

In  90  per  cent,  of  a  series  of  656  healthy  young  men, 
Barach  and  Marks^  found  that  the  systolic  blood-pressure 
was  150  mm.  Hg.,  and  in  96  per  cent,  of  the  338  persons, 
the  diastolic  pressure,  read  at  the  fifth  point,  did  not  exceed 
100  mm.  Hg.,  while  in  87  per  cent,  of  a  series  of  312,  the 
diastolic  pressure,  read  at  the  fourth  point,  did  not  exceed 
100  mm.  Hg.  In  88  per  cent,  of  a  series  of  629,  the  pulse 
pressure  ranged  between  20  and  70  mm.  Hg. 

J.  W.  Fisher^  is  firmly  of  the  opinion  that  a  systolic 
pressure  that  is  persistently  above  the  average  (see  page 
114)  by  more  than  15  mm.  for  a  given  age,  "should  excite 
suspicion  and  call  for  further  examination,  as  we  find  that 
an  abnormally  high  pressure  has  been  noted  in  about  6.5 
per  cent,  of  all  applicants  declined  for  insurance  in  the 
Northwestern  Mutual  Life  Insurance  Company." 

As  far  as  can  be  gathered  from  many  published  reports 
of  blood-pressure  tests,  a  maximum  diurnal  variation  of  36 
mm.  in  normal  individuals  does  not  exceed  normal.  If 
we  accept  this,  then  a  variation  of  17  mm.  above  or  below 
the  normal  estimated  average  may  be  allowed.  Thus  at 
age  twenty  any  reading  of  over  137  or  below  103  would  call 
for  explanation,  while  at  age  fifty,  the  permissible  variation 

1 H.  H.  Barach  and  W.  L.  Marks,  Arch.  Int.  Med.,  Apr.  15,  1914, 
xiii,  4. 

2  Jour.  A.  M.  A.,  1914,  No.  14. 


BLOOD-PRESSURE    IN    LIFE    INSURANCE  403 

lies  between  152  mm.  and  118  mm.  In  all  determinations 
of  blood-pressure,  the  factor  of  the  diameter  of  the  cuff 
employed  must  be  considered,  assuming  of  course  that  the 
accuracy  of  the  instrument  itself  is  beyond  dispute. 

At  the  present  time  the  accepted  standard  for  the  width 
of  cuff  is  between  Ai^i  and  5  in.  (11  cm.  to  13  cm.).  A  cuff 
of  narrower  width  gives  higher  readings  proportionately  to 
the  narrowness  of  the  cuff,  and  the  height  of  the  pressure. 

Application. — As  a  routine  measure,  the  left  arm  should 
be  employed  and  be  bared  to  permit  application  of  the 
cuff.  Both  patient  and  operator  should  be  in  comfortable 
positions,  by  preference  the  sitting  posture.  Time  also 
should  be  allowed  for  the  circulation  to  become  quieted,  as 
after  rapid  walking,  stair  climbing,  etc. 

Physiologic  variations  need  not  confuse  the  examiner, 
as  they  all  occur  within  a  range  sufficiently  restricted  to 
prevent  obscuration  of  the  issue. 

One  should  never  fail  to  discount  the  psychic  element 
which  may  be  great.  Fear  and  apprehension  on  the 
part  of  the  applicant  may  occasion  a  sharp  rise,  so  that 
in  cases  bordering  on  high  it  is  well  to  disregard  the  first 
reading,  as  the  second  and  third  readings  would  likely  be 
more  normal. 

Relation  of  Systolic,  Diastolic  and  Pulse  Pressures. — 
Generally  speaking  the  systolic  and  diastolic  and  pulse 
pressures  should  approximate  the  relationsip  of  3:2:1,  i.e., 
S.P.  130;  D.P.  86;  P.P.  44;  thus  the  pulse  pressure  is 
one-half  of  the  diastolic  pressure  and  one-third  of  the  sys- 
tolic pressure.  To  put  it  still  more  simply,  any  condition 
in  which  the  pulse  pressure  multiplied  by  three  greatly 
exceeds   the  systolic  pressure  is  an  indication  of  cardiac 


404  BLOOD-PRESSURE 

overwork  and  suggests  the  probability  of  arterial  and 
myocardial  involvement.  On  the  other  hand  should  three 
times  the  pulse  pressure  be  much  less  than  the  systolic 
pressure  there  is  evidence  of  great  physical  or  circu- 
latory weakness.  Persons  who  show  these  variations 
should  be  regarded  with  suspicion,  even  when  the  systolic 
pressure  alone  is  approximately  normal  for  the  given 
age. 

In  chronic  nephritis  during  cardiac  compensation  the 
pulse  pressure  is  often  very  large,  at  times  numerically 
approximating  the  diastolic  pressure,  while  in  aortic  in- 
sufficiency very  large  pulse  pressures  are  met;  this  varia- 
tion is  said  to  be  pathognomonic  of  this  condition.  Thus 
in  a  case  recently  under  observation  the  systolic  pressure 
averaged  145,  the  diastolic  pressure  40  (auscultatory, 
fourth  phase)  and  the  pulse  pressure  105  mm. 

Chronic  Albuminuria  and  Blood-pressure. — In  cases 
showing  chronic  albuminuria  great  importance  is  attached 
to  the  systolic  blood-pressm-e,  for,  if  after  about  ten  years 
of  recurrent  albuminuria,  the  pressure  is  not  found  to  be 
unduly  elevated,  the  urinary  findings  may  be  considered 
far  less  grave  than  they  would  be  otherwise.  In  this 
connection  a  case  is  now  under  my  observation  that  was 
rejected  for  insurance  over  eighteen  years  ago,  and  yet 
the  systolic  pressure  never  has  been  observed  to  be  higher 
than  130  and,  although  the  urine  still  shows  traces  of 
albumin,  he  appears  to  be  in  good  health.  While  this  may 
be  considered  an  extreme  example,  nevertheless  it  is  to 
the  point,  as  similar  cases  of  shorter  duration  can  be 
cited  in  large  numbers.  It  is  the  experience  of  all  who 
daily  employ  the   blood-pressure   test   to   encounter  not 


BLOOD-PRESSURE    IN    LIFE    INSURANCE  405 

only  albumin,  but  also  casts,  in  persons  with  normal  blood- 
pressure,  and  where  the  urinary  findings  are  probably  purely 
metabolic. 

Nephritis. — Bearing  in  mind  the  difficulty  of  early 
diagnosis  in  cases  of  chronic  nephritis  by  a  single  uri- 
nalysis, particularly  in  individuals  apparently  in  normal 
health,  the  importance  of  a  blood-pressure  test  will  be 
apparent,  because  it  is  recognized  that  we  cannot  have 
permanent  kidney  change  without  a  constant  elevation 
in  blood-pressure,  and  even  in  the  presence  of  albumin  or 
casts  we  may  question  their  true  significance.  Here  a 
persistently  high  blood-pressure,  say  150  mm.  or  over,  in 
an  individual  below  middle  age  will  settle  the  question  at 
least  in  regard  to  the  risk.  The  presence  alone  of  scanty 
albumin  and  casts  in  the  urine  is  not  conclusive  evidence  of 
a  diseased  kidney,  as  these  elements  may  come  from  any 
number  of  transitory  and  comparatively  unimportant 
complications.  The  blood-pressure  test  will  serve  as  a 
check,  so  that  the  applicant  with  a  normal  blood-pressure 
whose  urine  has  occasionally  shown  albumin  and  casts  will 
not  immediately  be  rejected,  and  such  individuals  will  get 
the  benefit  of  the  doubt  and  the  company  thereby  be 
prevented  from  committing  perhaps  a  grave  injustice. 

Overweights. — The  overweights  demand  careful  con- 
sideration by  the  insurance  examiner.  This  is  a  group 
which  shows  an  unfavorable  mortality  in  life  insurance 
statistics,  particularly  in  the  higher  ages.  It  should  be 
remembered  that  the  amount  of  adipose  tissue  covering 
the  vessels  does  not  materially  affect  the  reading,  as  cases 
of  very  large  arms  present  readings  of  normal  or  even 
below,  so  that  findings  of  high  pressure  should  be  attributed 


406  BLOOD-PRESSURE 

to  some  other  cause.  In  a  person  of  moderate  overweight 
in  whom  nothing  in  the  physical  examination  or  history 
indicates  rejection,  the  final  decision  is  often  made  upon  the 
relation  of  the  blood-pressure  test.  The  risk  is  accepted 
when  pressure  is  found  normal  and  declined  when  the 
pressure  approaches  or  passes  the  high  normal  limit. 

Chronic  Myocarditis.— This  is  probably  one  of  the  most 
difficult  conditions  to  diagnose  that  is  encountered  in  the 
course  of  insurance  work.  Its  possible  presence  must  al- 
ways be  borne  in  mind  and  every  effort  made  to  eliminate  it 
in  the  examination,  particularly^  in  those  past  middle  life, 
and  in  those  presenting  past  history  of  hard  physical  labor, 
excessive  brain  work,  alcoholism  or  syphilis.  This  will  of 
course  not  be  difficult  to  recognize  when  the  disease  has  pro- 
gressed sufficiently  to  affect  the  general  health  of  the  individ- 
ual. It  is  in  the  early  stages,  where  the  usual  methods  of  ex- 
amination fail  to  reveal  it,  that  the  sphygmomanometer  is  of 
greatest  value.  In  the  early  cases  the  systolic  pressure 
need  not  be  materially  affected,  so  that  recourse  must  be 
had  to  the  functional  tests  of  Graiipner  and  Shapiro,  and 
to  a  study  of  the  diastolic  and  pulse  pressures,  by  which 
changes  in  normal  reserve  of  the  heart  and  the  strength  and 
volume  of  its  output  can  be  estimated  (see  page  331). 

Incipient  Tuberculosis. — The  presence  of  a  shghtly 
lowered  blood-pressure  accompanied  by  slight  elevation 
in  pulse  rate,  with  or  without  fever,  combined  with  a 
history  of  sHght  loss  of  weight,  is  very  suggestive  evidence 
of  an  existing  pulmonary  lesion.  In  tuberculosis  the  blood- 
pressure  is  usually  low  and  the  pulse  pressure  diminished. 

In  this  connection  Haven  Emerson^  states  that  hypo- 

1  Arch.  Int.  Med.,  1910. 


BLOOD-PRESSURE    IN    LIFE    INSURANCE  407 

tension  is  found  in  almost  all  cases  of  moderately  advanced 
tuberculosis  and  that  it  has  been  found  by  many  observers 
in  early  doubtful  or  suspected  cases  with  or  without 
physical  signs  of  the  disease  of  the  lungs,  and  that  it  is 
considered  by  competent  clinicians  as  a  most  useful  sign. 
Cook  also  states  that  low  blood-pressure,  if  persistently 
found  in  individuals  or  in  families  should  put  us  on  our 
guard  for  tuberculosis.  In  applicants  of  light  weight  and 
a  blood-pressure  of  100  or  under  and  of  poor  family  history, 
the  risk  is  bad  (see  also  page  203). 

Blood-pressure  in  Relation  to  Mortality. — Dr.  J.  W. 
Fisher  of  the  Northwestern  Mutual  Life  Insurance  Com- 
pany,^-^  has  produced  some  very  valuable  work  by  drawing 
conclusions  from  a  study  and  analysis  of  the  mortality 
statistics  of  that  company  beginning  in  1907  and  con- 
tinuing until  August  1,  1913.  This  report  amply  confirms 
present  opinions  regarding  the  value  of  the  blood-pressure 
test  in  detecting  beginning  disease  of  the  cardiovascular 
and  renal  systems,  and  their  influence  on  expected 
mortality. 

From  a  study  of  2661  insured  taken  from  the  actuary's 
tables  giving  blood-pressure  readings  between  140  and  149 
mm.  Hg.,  with  81.85  expected  deaths,  thirty-one  actual 
deaths,  a  percentage  of  37.87,  which  was  slightly  below  the 
normal  death  rate  of  the  company  on  exposure  of  two  years. 
He  shows  another  table  of  mortality  records  of  527  insured 
persons  with  a  blood-pressure  reading  of  150  mm.  Hg.  and 
over,  with  22.19  expected  deaths  and  actual  deaths  twelve, 
which  is  about  35  per  cent,  in  excess  of  the  general  average 

^Med.  Rec,  Oct.  21,  1911. 

2  Jour.  A.  M.  A.,  Nov.  14,  1914,  Ixiii,  20,  p.  1752. 


408  BLOOD-PRESSURE 

mortality  of  the  company  covering  the  same  period  and 
10  per  cent,  higher  than  the  general  average  mortality 
during  the  first  five  years  of  exposure  covering  the  twenty 
years  period  1885  to  1905.  He  further  shows  a  mortality 
record  of  1970  applicants  rejected  with  an  average  systolic 
pressure  of  161.44  with  a  mortality  of  190  per  cent,  of  the 
medico-actuarial  table,  which  is  more  than  double  the 
average  mortality  of  that  company. 

In  another  table  are  shown  1082  cases  rejected  in  which 
there  were  reported  no  other  impairments  than  high 
blood-pressure  at  the  time  the  application  was  received 
at  the  home  office.  The  expected  deaths  were  34.78,  the 
actual  deaths  40,  or  179.53  per  cent,  of  the  table.  Efforts, 
made  to  follow  carefully  these  rejected  risks  in  order  to 
secure  data  as  to  the  subsequent  physical  condition  of  these 
applicants,  more  than  justified  the  opinion  that  the  sphyg- 
momanometer was  one  of  the  earliest,  if  not  the  very 
earliest,  means  of  detecting  departures  from  normal  in 
this  group  of  cases,  as  many  impairments  were  later  dis- 
covered or  developed  in  a  large  number  of  cases  rejected 
for  high  pressure  only. 


CHAPTER  XXIII 

THF    THERAPEUTIC    VALUE    OF    DRUGS    AFFECTING 

BLOOD^ESSTOE    AND    THOSE    COMMONLY 

EMaOYED  IN  CARDIOVASCULAR  AND 

RENAL  CONDITIONS 

In  the  revision  of  this  work,  it  became  apparent  that  it 
was  inadvisable,   if  not  indeed   impractical,  to  include  a 
discussion  of  the  management  of  the  many  cond.tions  m 
which  high  blood-pressure  is  a  factor,  as  it  would  extend 
beyond   convenient   limits   of   size.     This   section   is   an 
effort  to  make  up  in  a  measm-e  what  to  soine  naay  have 
appeared  a  regrettable  omission,  noting  briefly  the  effects 
which  may  be  expected  to  follow  the  employment  of  those 
drugs  which  axe  reputed  to  affect  blood-pressure,  but  with 
no  attempt  to  outline  definite  methods  for  the  management 

of  any  specific  cases.  .  ^  ^u  *     f 

We  recognize  from  the  therapeutic  standpomt  that  ol 
even  greater  importance  than  the  employment  of  drugs 
is  the  conservation  of  cardiac  energy,  the  development  of 
circulatory  competence  and  the  promoting  of  ehmmation; 
and  finally  that  the  reduction  of  abnormally  high  pressures 
is    only    of    secondary    importance.     Summing    up    our 
knowledge  of  the  therapeutic  action  of  the  majority  of 
drugs  heretofore  relied  upon  for  the  control  and  manage- 
ment of  circulatory  and  blood-pressmre  changes,  it  may 
be  said  that  our  confidence  in  these  drugs  has  been  too 
great,   and  as  a  rule  mistaken.     Thus  the  expermienta 


410  BLOOD-PRESSURE 

made  by  A.  Watson^  upon  the  vaue  of  drugs  as  blood- 
pressure  elevators  were  most  disappointing,  as  he  has 
shown  that  in  the  adult  male,  atropin,  camphor,  cotarnin, 
digitoxin,  ergotoxin  and  strychnin  appear  to  be  of  no 
value  as  blood-pressure  elevators,  while  epinephrin  is  a 
dangerous  drug  which  should  always  be  used  with  great 
caution  and  never  as  a  general  blood-pressure  elevator. 
Physostigmin  is  an  effective  blood-pressure  elevator,  but 
on  account  of  the  distressing  nausea,  vomiting  and  faint- 
ness  which  it  produces,  its  use  in  hypotension  does  not 
seem  advisable.  This  same  general  attitude  toward  drug 
therapy  in  blood-pressure  changes  is  held  by  Janeway.^ 
While  these  may  be  extreme  opinions,  they  nevertheless 
serve  to  show  the  trend  of  scientific  thought  in  the  matter 
of  the  drug  treatment  of  blood-pressure  variations,  as 
they  show  that  we  often  meet  failure  to  obtain  an  effect 
just  when  most  urgently  required.  Even  under  the  most 
favorable  circumstances  drug  action  is  not  only  of  short 
duration,  but  most  uncertain  and  irregular. 

In  the  following  pages  for  convenience  in  reference  the 
drugs  considered  are  in  alphabetic  order,  irrespective  of 
their  therapeutic  effect  or  their  actual  value  in  influencing 
blood-pressure. 

Aconite. — This  drug,  in  its  various  official  preparations, 
is  usually  looked  upon  as  a  vasodilator,  although  strictly 
speaking  it  accomplishes  a  fall  of  blood-pressure  through 
its  action  upon  the  vagus,  causing  a  marked  slowing  of  the 
pulse  which  is  accompanied  hy  a  reduction  in  blood- 
pressure.     In  overdoses  a  dangerous  fall  in  pressure  may 

^  The  Practitioner,  London,  April,  1915,  xciv,  4. 
2  Jour.  A.  M.  A.,  June  5,  1915,  Ixiv,  23. 


VALUE    OF   DRUGS    AFFECTING   BLOOD-PRESSURE  411 

be  produced,  accompanied  by  a  small  and  rapid  pulse.  Its 
use  has  been  recommended  in  interstitial  nephritis,  where 
it  is  said  to  favorably  influence  urea  elimination.^  It 
may  be  safely  used  in  cases  of  high  pressure  where  the 
heart  is  hypertrophied  and  the  valves  intact.  It  is  also 
often  employed  in  eclampsia  with  good  results.  In  the 
presence  of  cardiac  dilatation  and  myocardial  insufficiency 
it  is  unsafe,  and  as  compared  with  veratium  viride,  it  is 
the  more  dangerous  because  more  active. 

Administration. — The  tincture  may  be  given  in  5  to  10 
drops  every  three  hours;  or  the  fluid  extract  2  to  4  drops 
at  the  same  intervals. 

Alcohol. — Alcohol  as  a  cardiac  stimulant  has  little  if 
any  effect  upon  blood-pressure,  although  the  capillary 
dilatation  following  its  use  may  be  accompanied  by 
a  slight  fall.  The  moderate  daily  use  of  alcoholic  beverages 
does  not  materially  influence  blood-pressure,  although  large 
amounts  of  beer,  owing  to  the  bulk  of  fluid  ingested,  may 
cause  a  temporary  rise  of  from  5  to  15  mm. 

The  present  feeling  toward  alcohol  is  that,  as  the  results 
when  used  habitually  may  be  pernicious,  and  as  there 
are  non-habit-forming  drugs  which  may  be  used  as  satis- 
factory substitutes,  alcohol  should  be  used  sparingly,  if  at 
all,  in  pathologic  conditions,  least  of  all  in  nephritis  and 
high  blood-pressure  cases. 

Arsenic. — This  drug  in  doses  of  }i  gr.  of  arsenic  trioxid, 
has  been  reported  by  some  observers,  among  them  Balfour, 
to  be  of  value  in  reducing  high  blood-pressure.  To  obtain 
an  effect  the  drug  should  be  administered  over  a  long  period 
of  time. 

*  W.  H.  Thompson,  Am.  Jour.  Med.  Sci.,  January,  1915,  cxlix,  1. 


412  BLOOD-PRESSURE 

THE  NITRITE  GROUP 

For  convenience  in  comparison  of  therapeutic  effect,  amyl 
nitrite  has  been  taken  as  an  example  of  the  group  of 
vasodilators,  a  number  of  which  are  discussed  below.  This 
group  of  drugs  belongs  to  that  large  and  indefinite  class 
known  as  depressomotor,  all  of  which  have  a  distinctly 
sedative  action  upon  the  lower  centers. 

The  several  drugs  belonging  to  this  group,  while  having 
much  in  common,  vary  greatly  in  the  degree  and  duration 
of  their  influence,  while  in  some  instances  the  full  effect  is 
obtained  only  by  toxic  doses.  For  comparison  of  this 
action,  see  Fig.  88.  A  fall  in  pressure  following  their 
administration  is  usually  accompanied  by  increased  urine 
excretion. 

The  most  important  vasodilators  are: 

Amyl  nitrite. 

Nitroglycerin. 

Sodium  nitrite  (potassium). 

Erythrol  tetranitrate. 

Mannitol  hexanitrate. 

Amyl  Nitrite. — On  account  of  its  volatility,  this  drug  is 
usually  dispensed  in  glass  pearls.  These  are  to  be  crushed 
and  the  vapor  immediately  inhaled.  The  first  effect  of 
inhalation  noted  is  hurried  and  panting  breathing,  followed 
by  progressive  muscular  weakness  and  cutaneous  flushing. 
Toxic  doses  gradually  reduce  reflex  activity  until  death 
occurs  from  respiratory  failure.^ 

Effect  nf  Circulation. — The  pulse  is  increased  in  frequency 
and  the  arterial  blood-pressure  rapidly  diminishes.  This 
action  is  due  to  a  dilatation  of  the  small  vessels  from  the 

»  H.  C.  Wood,  "Therapeutics,"  J.  B.  Lippincott  Co.,  Philadelphia. 


VALUE    OF    DRUGS    AFFECTING   BLOOD-PRESSURE  413 

direct  action  of  the  drug  circulating  in  the  blood  upon  the 
walls  of  the  arterioles  and  capillaries.  At  the  same  time 
the  drug  has  a  minor  influence  on  the  vasomotor  centers. 

Administration. — This  is  usually  by  inhalation,  but  it 
may  be  by  the  mouth  or  hypodermically.  Dose  by  in- 
halation }'2  mm.;  by  the  mouth  two  to  three  drops  on  a 
lump  of  sugar  to  be  taken  instantly;  hypodermically,  1 
to  3  mm.  The  drug  is  comparatively  free  from  danger; 
as  much  as  two  drams  given  within  two  hours  have  been 
without  serious  effect  (Wood). 

Nitroglycerin  (See  Fig.  88). — This  drug  is  usually  admin- 
istered hypodermically,  although  it  may  be  administered 
by  the  mouth  in  tablet  form,  when  the  same  effect  is  ob- 
tained, although  with  less  rapidity.  There  is  considerable 
difference  of  opinion  in  regard  to  the  proper  dosage  of 
nitroglycerin. 

Von  Noorden^  gave  at  a  single  dose  53^  gr.;  Hochaus,^ 
7  gr.;  Himmelshach,^  2>^  gr.  On  the  other  hand,  severe 
collapse  has  resulted  from  comparatively  small  doses,  as 
1.12  gr.  (Loeb).  Initial  large  doses  should  never  be  given; 
3^00  gr-  is  the  usual  dose,  although  }{o  may  be  used  with 
safety,  though  when  a  fall  in  pressures  does  not  occur  with 
}io  gr-,  there  is  usually  little  to  be  expected  from  a  larger 
dose. 

Sodiiim  Nitrite  (See  Fig.  88). — Matthiew,"  studying 
the  effect  of  this  drug  on  ten  patients,  found  that  in 
six  an  average  fall  of  30  mm.  or  more  followed  the  adminis- 

^  C.  von  Noorden,  "Discussion  on  Arteriosclerosis,"  Cong.  f.  inn.  Med., 
1904,  xxi,  152. 

2  "Discussion  on  Arteriosclerosis,"  Cong.f.  inn.  Med.,  1904,  xxi,  165. 

3  G.  Himmelsbach,  Med.  News,  Phila.,  1893,  Ixii,  14. 
<  Quart.  Jour.  Med.,  No.  2,  p.  261. 


414 


BLOOD-PRESSURE 


tration  of  2-gr.  doses.  In  one  case  a  maximum  drop  of 
75  mm.  was  recorded,  which,  however,  was  extremely 
transitory,  the  pressure  having  returned  almost  to  the 
usual  level  in  thirteen  minutes,  although  the  return  to 
normal  after  employing  this  drug  is  usually  slower  than  in 
nitroglycerin. 

Administration. — Tablets  of  from  }4  to  2  gr.  Solutions, 
when  fresh,  are  potentially  more  active,  but  tend  to 
decompose  rapidly. 


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Fig.  88. — Chart  showing  relative  effect  upon  systoHc  blood-pressure  and 
duration  of  action  in  minutes  of  nitroglycerin,  sodium  nitrite  and  erythrol 
tetranitrate,  after  Miller  (Jos.  L.  Miller,  Jour.  A.  M.  A.,  liv,  21,  1910, 
p.  1666). 

Erythrol  Tetranitrate  (Fig.  88). — The  same  observer 
following  the  administration  of  J^-gr.  tablet  obtained  a  fall 
of  30  or  more  millimeters  in  five  persons,  of  15  mm.  in  two, 
while  one  person  was  unaffected.  In  one  case  a  maximum 
fall  of  110  was  accompanied  by  collapse.  Headache  is  a 
common  accompaniment  and  does  not  necessarily  follow 
the  degree  of  blood-pressure  reduction. 

Mannitol  Hexanitrate. — The  use  of  this  drug  is  usually 
followed  by  a  more  prolonged  reduction  in  pressure  than. 


VALUE    OF   DRUGS    AFFECTING   BLOOD-PRESSURE  415 

is  produced  by  any  of  the  preceding.     It  is  usually  given 
in  doses  of  1  to  2  gr. 

The  following  table  has  been  constructed  from  the  cHnical 
statistical  reports  of  Wallace  and  Ringer/  Matthiew/  J. 
L.  Miller/  and  Lauder  Brunton.^ 


Drug 


Efifectual 
dose 


Begin 
effect 


Max. 
effect  in 


Mm. 
reduct. 


Duration 


Dose, 
inter- 
val 


Amyl  nitrite 

Nitroglycerin 

Sodium  and  potassium  nitrite 

Erythrol  tetranitrate 

Mannitol  hexanitrate 


1-3  mm. 
inhalation 
1-2  mm. 
\'i-2  gr. 
0.5-1.5 
1  gr. 


1  min. 

2  min. 
6  min. 
4  min. 


2  min. 

2-10  min. 

8-15min. 

15  min. 


20-40 

20-40 

5-30 

15-50 


7  min. 


P.R.N. 


30-40  min.   1-2  hr. 


1-"^  hr. 

4-6  hr. 

6  hr. 


T.i.d. 
4-6  hr. 
4-6  hr. 


Before  employing  any  drug  in  this  group,  it  should  be 
carefully  ascertained  that  the  drug,  particularly  sodium 
nitrite,  is  strictly  fresh,  as  failure  to  obtain  the  desired 
effect  may  be  due  entirely  to  the  use  of  an  inactive  prepara- 
tion. Tablet  preparations  are  known  to  vary  greatly 
in  strength  and  should  be  of  standard  make.  This  defect 
can,  according  to  some  observers,  be  avoided  by  the 
employment  of  fresh  chocolate  tablet  preparations. 
Sodium  nitrite  in  solution  rapidly  loses  its  activity  and 
should  not  be  kept  for  more  than  one  week.  All  these 
drugs  may  be  employed  hypodermically  when  desired,  but 
for  continued  use  should,  if  possible,  be  given  by  the 
mouth. 

According  to  Wallace  and  Ringer,  it  may  be  stated  that, 
as  a  general  rule,  the  higher  the  original  pressure,  the  greater 

1  Jour.  A.  M.  A.,  No.  20,  p.  1629. 

^Loc.  cit. 

3  Jour.  A.  M.  A.,  May  21,  1910,  liv,  21,  p.  1666. 

*  Loc.  cit. 


416  BLOOD-PRESSURE 

the  fall  produced.  They  were  able  in  theu*  experiments  to 
obtain  a  reduction  in  pressure  in  every  case,  and  the  effect 
of  an  equal  dose  upon  the  pressure  in  arteriosclerosis  was 
the  same  as  the  effect  of  an  equal  dose  upon  a  normal  indi- 
vidual.    My  own  experience  does  not  substantiate  this. 

Daniel  Hoyt^  arrives  at  the  same  conclusion,  but  advo- 
cates the  use  of  larger  doses  than  those  generally  employed, 
attributing  failure  to  obtain  satisfactory  results  to  insuffi- 
cient dosage  or  the  employment  of  inactive  preparations. 
This  difficulty  is  largely  removed  when  the  chnician  employs 
the  sphygmomanometer  to  check  his  results. 

Rudolph  notes  that  the  effect  of  the  vasodilators  may 
vary  from  day  to  day,  and  in  this  connection  Miller^ 
brought  out  a  very  interesting  as  well  as  a  most  important 
point  in  the  chnical  action  of  these  drugs,  namely,  that 
wide  variation  in  their  effect  may  occur  not  only  from  day 
to  day,  but  that  different  drugs  of  the  same  group  may 
affect  the  same  individual  differently.  He  reports  the 
following  specific  instances: 

Case  1. — Sodium  nitrite  had  no  effect  whatever,  nitro- 
glycerin caused  a  reduction  of  50  mm.,  erythrol  tetranitrate 
resulted  in  a  rapid  fall  of  110  mm.,  the  patient  going  into 
collapse. 

Case  2. — Nitroglycerin  and  erythrol  tetranitrate  had 
very  little  effect  upon  the  pressure  while  a  reduction  of  65 
mm.  follov/ed  the  usual  dose  of  sodium  nitrite. 

Case  3. — Nitroglycerin  caused  a  fall  of  30  mm.,  sodium 
nitrite  a  fall  of  20  mm.,  and  erythrol  tetranitrate  a  fall  of 
15  mm. 

1  Intemat.  Clinics,  Vol.  i,  1912. 

2  Loc.  cit. 


VALUE    OF   DRUGS   AFFECTING   BLOOD-PRESSURE  417 

Atropin. — Atropin  has  little  if  any  effect  on  blood-pressure 
in  normal  individuals,  its  chief  circulatory  effect  being  to 
depress  the  vagus  terminations  and  to  accelerate  the  pulse. 
This  acceleration  is  often  accompanied  by  a  correction  of 
functional  arhythmias. 

In  cases  of  pulmonary  edema  and  vascular  collapse  this 
drug  is  of  great  value  in  controlUng  leaky  skin  and  wet  lungs. 
Here  the  result  is  as  rapid  as  it  is  satisfactory  (see  Fig.  69). 

Administration. — Usually  by  hypodermic,  in  doses  of 
from  3^00  to  }io  gr.  repeated  p.r.n.  In  the  form  of  bella- 
donna it  is  most  valuable  in  doses  of  from  3  to  5  mm.  in 
supporting  the  circulation,  often  turning  the  tide  in  the 
patient's  favor. 

Caffein. — The  usual  opinion  seems  to  be  that  caffein 
causes  a  marked  rise  in  blood-pressure  with  an  increase  in 
pulse-rate  and  that  the  rise  in  blood-pressure  is  due  in 
part  to  the  increased  heart  action,  and  in  part  to  the  con- 
traction of  the  blood-vessels  caused  by  a  stimulation  of  the 
vasomotor  centers  in  the  medulla.  The  observations  of 
H.  C.  Wood,  Jr.^  in  a  careful  study  of  four  subjects,  where 
every  effort  was  made  to  eliminate  psychic  and  other 
extraneous  influences,  show  that  in  the  entire  four  there 
was  never  a  marked  rise  in  blood-pressure,  the  average  rise 
for  his  whole  series  being  but  2.2.  mm.  This  was  accom- 
panied by  a  reduction  in  pulse  rate,  occasionally  quite 
marked.  In  Wood's  experiments  the  doses  of  caffein 
range  from  13>^^  to  6  gr.,  and  were  administered  under  such 
conditions  that  the  subjects  were  unaware  when  they  were 
receiving  the  drug.  The  protocol  of  Wood's  experiments 
follows : 

1  Therap.  Gaz.,  Jan.  15,  1912. 
27 


418  BLOOD-PRESSURE 

Wood's  Table  Showing  the  Details  of  Two  Studies  on  the  Human 

Blood-pressure 

Subject  I 


Time 

B.P. 

P.P. 

P.R. 

Time 

B.P. 

P.P. 

P.R. 

Begin. 

84 

27 

53 

Begin. 

88 

28 

57 

0.15 

83 

22 

54 

0.15 

84 

34 

60 

0.40 

87 

21 

50 

Starcli  IVigT. 

0.45 

84 

30 

55 

1.00 

90 

29 

53 

at  0.25. 

1.00 

93 

26 

54 

1.10 

84 

23 

1.15 

93 

26 

54 

1.20 

91 

22 

56 

1.30 

95 

22 

54 

Caffein  6  gr.  at 

1.45 

97 

25 

52 

0.20. 

2.10 

96 

19 

54 

2.20 

95 

22 

58 

2.40 

97 

22 

54 

2.50 

96 

23 

58 

3.05 

96 

22 

53 

Time  is  expressed  in  hours  and  minutes.  B.P.  indicates  mean  blood-pressure,  obtained 
by  adding  together  the  diastolic  and  systolic  pressures  and  dividing  by  2;  P.P.  or  pulse- 
pressure  is  the  diSerence  between  the  systolic  and  diastolic  pressures;  P.R.  is  the  pulse-rate 
per  minute. 

Wood's  Table  Showing  the  Averages  of  all  the  Observations  on  the 
Effects  of  Caffein  on  Circulation  of  Human  Beings 


Normal 

One-half 

hour  after 

caffein 

One  hour 
after 
caffein 

Two  hours 

after 

caffein 

Subject  1 

B.P.       P.R. 

85         62 

94         86 

HI         53 

98        81 

B.P.       P.R. 

87         57 

95         79 

HI         52 

98        75 

B.P.       P.R. 

92  56 

93  81 
112         52 

97        73 

B.P.       P.R. 
94        56 

Subject  2 

91         84 

Subject  3 

Subject  4 

112         51 
100        71 

Average 

97.0     70.5 

97.8     65.6 

99.0     65.4 

99.2     65.4 

From  the  work  of  J.  D.  Pilcher^  it  appears  that  caffein 
in  excessive  doses  is  accompanied  by  a  lowering  of  systolic 
pressure,  accompanied  by  an  increase  in  heart  rate,  while 
in  toxic  doses  death  may  result  from  acute  cardiac  dilatation. 
The  stimulating  action  of  caffein  is  more  prompt  but  less 
persistent  than  digitahs.     Coffee  by  mouth  or  by  rectum, 

^  Jour.  Pharmacol,  and  Exp.  Therap.,  July,  1912,  iii,  6. 


VALUE    OF   DRUGS    AFFECTING   BLOOD-PRESSURE  419 

and  also  tea  to  a  less  extent,  have  the  same  action  due  to 
their  containing  this  drug. 

Calomel. — Lauder  Brunton  advises  the  employment  of 
calomel  in  3^-gr.  doses  three  or  four  times  a  day  to  re- 
lieve hypertension.  In  kidney  involvement  the  giving  of 
mercury  in  any  form  is  usually  inadvisable. 

Camphor. — This  drug  finds  great  favor  as  a  rapid  and 
powerful  cardiac  stimulant,  as  it  may  be  relied  upon  even 
in  the  last  stages  of  cardiac  failure.  Experimental  evi- 
dence tends  to  show  that  it  has  very  little  influence  upon 
blood-pressure,  and  it  is  rarely  employed  for  this  effect. 

Chloral  may  greatly  relieve  the  symptoms  of  high  blood- 
pressure,  even  without  materially  altering  the  level. 
Indeed  it  does  not  as  a  rule  have  much  effect  on  high 
blood-pressure. 

Chloroform. — This  drug  always  produces  a  fall  in  blood- 
pressure,  which  progressively  increases  with  the  duration 
of  its  administration,  when  used  in  concentrated  form,  as 
little  as  3  c.c.  has  been  known  to  cause  a  dangerous  fall. 
Its  employment  is  dangerous  in  all  degenerative  conditions 
with  hypotonus,  and  while  advocated  by  some  clinicians 
as  an  emergency  remedy  to  reduce  high  pressure,  it  should 
not  be  used  if  anything  else  is  at  hand  which  will  accomplish 
the  same  result. 

Cocain. — According  to  Cook  and  Briggs,  low  tension 
after  hemorrhage  is  favorably  affected  by  this  drug;  )^ 
to  yi  gr.  hypodermically  is  usually  followed  by  an  almost 
immediate  rise  in  pressure  of  from  10  to  20  mm.,  which 
is  maintained  from  one  to  three  hours. 

Digitalis  and  Its  Preparations. — Digitalis  has  not  yet 
been  accurately  placed,  at  least  in  regard  to  its  effect  upon 


420  BLOOD-PRESSURE 

the  blood-pressure.  Owing  to  its  cumulative  action,  the 
marked  degree  of  local  irritation  usually  following  the  use 
of  preparations  of  the  crude  drug,  and  the  slowness  of  its 
action,  it  is  of  less  value  than  it  otherwise  might  be  in 
acute  conditions  and  in  emergency.  Further,  the  older 
preparations  of  this  drug  are  so  variable  in  their  activity 
that  they  cannot  be  depended  upon.  Thus  I  have  seen 
no  effect  follow  the  administration  of  20-minim  doses  of  a 
poor  preparation  and  good  results  often  accrue  from 
5  minims  of  an  active  tincture.  This  criticism  applies  less 
strongly  to  such  modern  preparations  as  digitoxin,  digalin 
and  digipuratum,  than  to  the  older  galenicals. 

Effect  on  Blood-pressure. — The  characteristic  results 
which  have  heretofore  been  attributed  to  digitalis  are 
largely  based  upon  experimental  work  and  may  be  sum- 
marized as  follows:  (a)  A  reduction  of  the  pulse  rate, 
ascribed  to  stimulation  of  the  inhibitory  mechanism;  (6) 
increase  in  the  force  of  cardiac  contraction  and  (c)  narrowing 
of  the  lumen  of  the  blood-vessels  by  the  combined  action 
of  this  drug  directly  upon  the  unstriped  muscle  and  upon 
the  vasomotor  centers  in  the  medulla.  It  is  upon  this 
data  that  the  common  belief  that  digitalis  raises  the 
systolic  pressure  has  been  founded.  More  recent  observa- 
tions by  careful  investigators  have  failed  to  demonstrate 
that  digitalis  can  be  included  in  the  class  of  drugs,  to  be 
depended  upon  for  elevation  in  blood-pressure.  Thus 
Cushny^  states  that  the  systolic  pressure  of  cardiac  patients 
is  rarely  raised  by  digitalis,  while  on  the  other  hand  it  may 
fall  as  improvement  sets  in.     E.  W.  Price,-  studied  thirty- 

*  Arthur  R,  Cushny,  Am.  Jour.  Med.  Sci.,  cxli,  p.  469,  1911. 
«  Brit.  Med.  Jour.,  Sept.  13,  1913,  ii. 


VALUE   OF   DRUGS    AFFECTING   BLOOD-PRESSURE  421 

seven  cases  of  which  twenty-six  were  cardiovascular  and 
in  which  the  blood-pressure  was  either  normal  or  sub- 
normal. In  all  except  five  there  was  no  demonstrable 
change  in  the  systolic  pressure  during  the  administration 
of  the  drug.  Of  the  five  cases  three  showed  a  fall  equal  to 
about  20  mm.  Hg.,  toward  the  end  of  the  administration. 
In  one  there  was  a  doubtful  fall  and  the  fifth  a  rise  equal  to 
about  20  mm.  This  was  in  a  case  of  double  aortic  disease 
with  a  mitral  systolic  murmur,  thickened  and  tortuous 
vessels,  cyanosis,  orthopnea,  slight  jaundice,  much  edema, 
and  slight  albuminuria,  and  with  a  pressure  varjring 
between  170  and  180  systolic. 

Lawrence^  cites  twenty-six  cases,  in  only  five  of  which 
was  there  demonstrated  a  rise  in  systolic  pressure,  the 
greatest  being  30  mm.,  occurring  in  a  case  of  acute  infec- 
tion involving  the  heart  and  kidneys  (which  cannot  be 
considered  as  properly  belonging  to  a  cardiovascular 
series),  four  showed  no  change  and  seventeen  showed  a 
fall  in  systolic  pressure,  either  during  or  immediately  after 
the  cessation  of  treatment,  nearly  all  showed  a  marked 
diuresis. 

Effect  on  Diastolic  Pressure. — In  Lawrence's  series  only 
one  showed  a  relative  increase  in  diastolic  pressure,  four 
exhibited  no  change  whatever,  while  twenty  showed  a  fall 
in  diastolic  pressure  with  an  increase  in  pulse  pressure, 
and  in  50  per  cent,  of  the  cases  in  this  group  this  change 
was  accompanied  by  diuresis. 

Administration. — In  fresh  infusion  5ii  to  3  iv  every  four- 
teen hours;  tincture  5  to  15  m.  digalin,  3  to  9  m.  in  twenty- 
four  hours,    digipuratum   0.1    c.c.  in   twenty-four   hours. 

1  C.  H.  Lawrence,  Boston  Med.  &  Surg.  Jour.,  Jan.  1,  1914,  clxx. 


422  BLOOD-PRESSURE 

A.  E.  Taussig^  lays  down  the  following  rules  for  the  adminis- 
tration of  this  drug.  In  mitral  stenosis  digitahs  should  not 
be  given  until  compensation  is  entirely  lost  and  then  only 
in  moderate  doses.  In  aortic  stenosis  with  myocarditis  the 
drug  may  be  given  irrespective  of  the  character  of  the  pulse. 

There  is  no  reason  why  digitalis  preparations  should  not 
be  safely  administered  to  patients  suffering  from  arterio- 
sclerosis, angina  pectoris  and  high  pressure  of  nephritic 
origin.  In  the  presence  of  decompensation,  it  has  been 
my  experience  that  the  administration  of  digitalis  prepa- 
rations, in  cardiovascular  cases  in  which  the  myocardium 
is  chiefly  at  fault,  is  often  accompanied  by  danger,  and 
that  its  effect  should  be  carefully  watched,  and  the  drug 
immediately  stopped  upon  the  development  of  increasing 
arhythmia  or  mental  disturbance. 

Contra-indications. — Partial  heart  block,  recent  embol- 
ism, cerebral  hemorrhage,  aortic  aneurism,  uremia,  hyper- 
thyroidism, the  cardiac  neuroses  and  in  aortic  insufficiency 
with  partial  heart  block. 

Epinephrin  (Adrenalin). — Despite  the  conflicting  reports 
upon  the  efficiency  of  adrenalin  as  a  supporter  of  failing 
blood-pressure,  a  critical  study  shows  that  this  drug  is 
probably  our  chief  support  in  emergency.  The  degree  to 
which  elevation  in  pressure  occurs  will  depend  largely  upon 
the  method  of  its  administration  (whether  continuous 
or  intermittent)  upon  the  nature  of  the  condition  present 
and  upon  the  ability  of  the  arterial  system  to  respond  to 
its  action.  According  to  Manswetowa^  as  small  an  amount 
as  1  c.c.  will  cause  a  rapid  and  sharp  rise  in  systolic  pressure, 

1  Interstate  Med.  Jour.,  xix,  p.  771. 

2  S.  M.  Manswetowa,  Russky  Vrach,  June  27,  1914,  xiii,  24. 


VALUE    OF    DRUGS    AFFECTING   BLOOD-PRESSURE  423 

while  the  diastoHc  pressure  falls.  Thus  bearing  out  the 
conclusions  formerly  reached  by  Hill.^ 

Spinal  Injections. — In  the  quantity  usually  employed  to 
induce  spinal  anesthesia  adrenalin,  has  no  effect  upon 
arterial  pressure. 

Administration. — Adrenalin  may  be  administered  by 
hypodermic  in  doses  of  3  to  10  minims,  and  by  hypo- 
dermoclysis  and  intravenous  injections  in  varying  dosage, 
depending  upon  the  rate  of  flow  through  the  needle  and 
the  extent  of  effect  desired.  The  action  of  adrenalin  when 
given  by  mouth  is  extremely  unreliable,  and  it  is  doubtful 
whether  absorption  from  the  stomach  takes  place  with 
sufficient  rapidity  to  allow  much  of  the  drug  to  be  absorbed 
before  its  activity  is  reduced  or  destroyed  by  the  fluids  in 
the  digestive  tract. 

MacKenzie  recommends  the  hypodermic  method  for 
emergency  use,  but  he  believes  frequent  repetition  is  neces- 
sary if  any  sustained  action  is  desired,  as  the  action  is  largely 
local,  and  because  the  product  is  rapidly  destroyed  after 
entering  the  blood-stream.  The  researches  of  W.  Straub^ 
confirm  the  assumption  that  adrenalin  has  no  cumulative 
action.  He  states  that  it  is  probable  that  this  substance 
is  destroyed  with  great  rapidity,  as  it  vanishes  from  the 
blood  completely,  just  as  rapidly  as  its  action  subsides. 
Its  action  is  exclusively  local,  that  is,  it  acts  on  the  vessels 
only  by  direct  contact.  This  appears  to  confirm  the 
opinion  that  the  continuous  infusion  of  a  weak  solution 
of  adrenalin  is  the  only  rational  method  of  employing  the 
drug,  when  continued  effect  is  desired.     Straub  found  it 

1  E.  C.  Hill,  Denver  Med.  Times,  April,  1912,  xxxi,  10. 

2  Miinch.  med.  Wochen,  Vol.  Ivii,  No.  26. 


424  BLOOD-PRESSURE 

possible  to  send  the  solution  continuously  into  a  vein  and 
thus  keep  blood-pressure  up  permanently,  as  long  as  the 
drug  was  continued,  the  effect  being  dependent  on  the 
concentration  of  the  solution,  and  not  on  the  absolute 
amount  of  adrenalin  infused. 

In  the  low  blood-pressure  of  shock,  Pearce  and  Eisen- 
brey^  recommend  the  slow  intravenous  administration 
of  adrenalin  salt  solution  (1-40,000)  combined  with  a  pure 
cardiac  stimulant  such  as  digitoxin.  They  obtained  rela- 
tively rapid  and  permanent  improvement.  In  this  same 
connection  A.  Rendel  Short^  found  that  the  addition  of 
adrenalin  to  normal  salt  solution  in  strength  up  to  1-20,000 
would  restrain  the  caliber  of  the  vessels  even  when  the 
vasomotor  center  was  powerless  and  that  apparently 
hopeless  cases  recovered  under  this  treatment. 

In  contrast  to  this  testimony  Brooks  and  Kaplan^  have 
reported  two  cases  where  adrenalin  was  used  as  the  thera- 
peutic agent  for  a  prolonged  time.  They  found  that  dur- 
ing continued  administration  adrenalin  gradually  lost 
its  power,  and  they  therefore  do  not  accept  the  common 
belief  that  adrenalin  will,  over  a  prolonged  period,  maintain 
a  constant  elevation  of  pressure. 

Ergot. — Ergot,  due  to  its  vasoconstricting  effect,  may  be 
rehed  upon  to  cause  a  slight  rise  in  blood-pressure.  This 
effect  contra-indicates  its  use  in  hemorrhage,  particularly 
pulmonary. 

Ethyl  Chlorid. — On  account  of  the  uncertainty  of  the 
action  of  this  drug  and  its  marked  effect  in  reducing  systolic 
pressure,  it  should  under  no  circumstance  be  employed 

1  Arch.  Int.  Med.,  August,  1910. 

*  Loc.  cit. 

'  Arch.  Int.  Med.,  Oct.  15,  1909. 


VALUE    OF   DRUGS    AFFECTING   BLOOD-PRESSURE  425 

therapeutically  for  its  effect  on  blood-pressure,  and  it  is 
especially  dangerous  when  used  as  an  anesthetic  in  the 
presence  of  myocardial  insufficiency. 

Guipsine  (Active  Principle  of  Mistletoe). — According  to 
Williamson/  this  drug  is  held  in  high  esteem  abroad,  par- 
ticularly in  France,  as  a  blood-pressure  reducer,  as  it  can 
be  relied  upon  to  sustain  its  action  for  a  period  of  days. 
It  is  administered  in  pill  form,  each  pill  being  standardized 
to  contain  the  equivalent  of  5  cgm.  of  the  active  principle 
of  mistletoe  and  to  be  given  in  doses  of  from  30  to  125 
cgm.  in  twenty-four  hours;  this  approximates  30-mm.  doses 
of  the  fluid  extract  of  mistletoe.  Toxic  symptoms  are 
extremely  rare  even  with  maximum  dosage. 

Hormonal. — H.  Mohr-  states  that  this  substance  is 
capable  of  greatly  reducing  blood-pressure  even  when  em- 
ployed in  amounts  far  below  the  dose  generally  adminis- 
tered clinically,  and  the  severe  symptoms  of  collapse  have 
been  reported  after  the  intravenous  administration  of  14 
c.c,  while  20  have  caused  death. 

lodin. — lodin  and  the  iodids  are  supposed  to  bene- 
ficially influence  degenerative  changes  in  the  vessel  walls 
and  have  long  been  advocated  for  the  treatment  of  high 
blood-pressure,  apart  from  those  cases  resulting  from 
syphilitic  infection,  where  of  course  it  is  indicated.  The 
profession  is,  however,  by  no  means  united  as  to  the  effi- 
ciency of  these  preparations,  which  at  present  do  not  find 
general  favor  in  the  treatment  of  arterial  tension.  Many 
believe  that  any  effect  following  the  employment  of  this 
drug  is  due  to  the  employment  of  coincident  measures, 

^  O.  K.  Williamson,  The  Practitioner,  London,  May,  1911. 
2  Wien.  klin.  Wochen,  May  16,  1912,  xxv,  20. 


426 


BLOOD-PRESSURE 


much  as  improved  hygiene,  the  elimination,  rest,  etc.     One 
drawback  to  the  continued  use  of  this  drug  and  its  salts 
is  the  irritation  which  its  use  causes  in  the  digestive  tract, 
lodin  is  usually  administered  in  the  form  of  potassium 

BLOOD  PRESSURE  CHART 


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Fig.  89. — Chart  shows  dangerous  effect  of  continued  overuse  of  sodium 
iodid.  lodid  was  begun  in  doses  of  5  gr.  three  times  a  day,  and  was  con- 
tinued until  April  1.  Pulse  became  irregular  and  patient  was  very  dizzy. 
Strychnin,  J-^o  gr.,  was  begun  on  April  14;  patient  then  left  city  for  summer. 
Did  not  return  until  September  16,  during  which  time  contrary  to  orders, 
he  persistently  took  between  25  and  30  gr.  sodium  iodid,  and  returned  in 
very  bad  condition.  The  rising  pressure  of  September  21  is  from  the  com- 
bined use  of  strychnin  and  digitalis. 

or  sodium  iodid,  and  as  there  is  no  difference  in  their  effect 
upon  the  circulation  and,  as  a  rule,  sodium  iodid  is  better 
tolerated,  the  sodium  preparation  should  be  employed.  No 
advantage  has  been  found  in  the  use  of  larger  doses  than 


VALUE    OF    DRUGS    AFFECTING   BLOOD-PRESSURE  427 

2  to  5  gr.  daily,  given  in  milk  or  diluted  with  water.  Some 
observers,  however,  recommend  the  use  of  an  ascend- 
ing dosage,  beginning  at  6  gr.  and  gradually  increasing  to  21 
gr.  a  day.  When  used  in  this  way  an  intermission  of  one 
week  should  occur  in  every  four  weeks  of  its  administration. 
Excellent  results  have  been  reported  in  some  cases  of  hy- 
pertension, but  there  was  no  proof  that  they  were  not  of 
syphilitic  origin.  The  accompanying  chart  shows  a  re- 
markable and  at  the  same  time  dangerous  effect  from  the 
overuse  of  iodid  (Fig.  89). 

The  disagreeable  effect  of  iodid  can  often  be  reduced  by 
the  addition  of  5  gr.  of  sodium  bicarbonate  to  each  dose. 

Morphin. — Morphin  has  long  been  recognized  as  a 
valuable  emergency  remedy  in  heart  disease  and  there 
are  probably  no  contra-indications  to  its  use.  In  doses  of 
/i  to  3^  gr.,  hypodermically,  it  may  be  relied  upon  in 
emergency  to  lower  systolic  pressure  and  improve  cardiac 
rhythm,  but  it  is  not  a  drug  for  continued  use.  The  value 
of  morphin  in  heart  disease  is  probably  due  to  its  effect 
in  breaking  up  the  vicious  circle  between  the  heart  and 
the  nervous  system. 

Pilocarpin. — Robinson^  states  that  both  the  pulse  rate 
and  the  blood-pressure  are  reduced  in  the  lower  animals 
by  this  drug,  and  that  while  similar  results  obtain  in  man, 
they  are  not  as  uniform.  He  states,  however,  that  he  has 
employed  pilocarpin  for  several  years  in  the  treatment 
of  practically  all  cases  of  high  blood-pressure  with  good 
results  in  most  instances,  and  reports  reduction  in  systolic 
pressure  amounting  to  30  or  40  mm.  after  four  to  six  weeks' 
treatment. 

1  Wm.  Duffield  Robinson,  N.  Y.  Med.  Jour.,  Nov.  7,  1914. 


428  BLOOD-PRESSURE 

Dosage. — One-thirtieth  of  a  grain  in  a  glassful  of  water 
after  meals.  Even  this  very  small  dose  may  be  further 
reduced  and  still  produce  good  results.  He  cautions 
against  over-dosage  and  recommends  a  close  watch  upon 
cardiac  action,  blood-pressure,  and  the  production  of 
sensible  sweat. 

Pituitary  Extract. — A  Rendel  Short  ^  considers  pituitary 
extract  more  valuable  than  adrenaUn  in  combating  marked 
reduction  in  blood-pressure,  since  its  action  is  more  pro- 
longed than  that  of  adrenalin.  It  is  not  cumulative,  and 
may  be  employed  hypodermically  over  a  long  period  of 
time.  The  commercial  preparation  of  pituitrin,  }i  to 
1  c.c.  of  the  preparation,  is  the  agent  of  choice;  the  studies 
of  Lewis,  Miller  and  Mathews^  report  variable  results  from 
preparations  made  from  the  several  divisions  of  this  gland. 
Remon  and  DeLille,^  prefer  the  extract  and  recommend 
3^-gm.  doses.  Arbuck  and  Rongy^  caution  against  the 
use  of  pituitrin  in  any  case  of  high  pressure  in  which  an 
increase  in  pressure  may  be  harmful.  They  found  that  an 
injection  of  1  c.c.  in  a  series  of  cases  studied  by  them 
causes  within  two  or  three  minutes  after  injection  a  rise 
averaging  from  25  to  35  mm.,  which  persisted  from  thirty 
to  forty  minutes,  followed  in  a  number  of  cases  by  a 
sudden  fall  to  below  the  original. 

Purging. — Neilson  and  Hyland^  have  studied  the  efifect 
of  magnesium  sulphate,  sodium  sulphate,  sodium  and 
potassium  tartrate  and  compound  jalap  powder,  in  the 

^  Loc.  cit. 

'D.  Lewis,  J.  L.  Miller  and  S.  A.  Mathews,  Arch.  Int.  Med.,  June,  1911. 

'  Quoted  by  Sajous,  loc.  cit. 

*  S.  S.  Arbuck  and  J.  A.  Rongy,  N.  Y.  Med.  Jour.,  May  2,  1914,  p.  878. 

eC.  H.  Neilson  and  R.  F.  Hyland,  Jour.  A.  M.  A.,  Feb.  8,  1913,  Ix,  6,  p.  436. 


VALUE    OF    DRUGS    AFFECTING   BLOOD-PRESSURE  429 

usual  therapeutic  doses,  from  which  they  noted  the 
following  effects: 

The  systolic  pressure  was  tested  in  126  patients,  of  whom 

109  showed  a  lowering  of  the  systolic  pressure  varying 
from  5  to  35  per  cent.  Twelve  showed  practically  the 
same  blood-pressure  throughout  the  experiment.  Five 
showed  an  increase  during  the  experiment.  Twenty-four 
hours  after  the  cathartic  was  given,  forty-eight  had  a  sys- 
tolic pressure  from  5  to  18  per  cent,  lower  than  before  the 
cathartic  was  given.  Twenty-six  had  practically  the  same 
as  at  the  beginning.  Only  those  who  remained  in  bed  were 
tested  twenty-four  hours  afterward.  The  action  of  the 
different  cathartics  was  practically  the  same,  except  that 
the  compound  jalap  produced  a  more  constant  and  greater 
lowering  than  the  others.  They  also  showed  in  most 
instances  quite  a  decided  lowering  at  the  end  of  twenty- 
four  hours.  It  was  found  in  this  set  of  experiments  that 
those  individuals  with  a  systolic  pressure  of  140  and  above, 
the  highest  tested  being  190,  gave  an  average  lowering  of  23 
mm.  Hg.     Fifty-seven  individuals  with  a  pressure  of  from 

110  to  140  gave  an  average  lowering  of  13  mm.  Hg.,  which 
thirty-four  individuals  with  pressure  110  or  lower  gave  an 
average  lowering  of  7  mm.  Hg. 

A  study  of  systolic,  diastolic  and  pulse  pressures,  and 
the  rate  of  heart  beat  was  made  on  sixty-eight  individuals. 

The  percentage  lowering  of  the  systolic  pressure  in  this 
number  taken  as  a  whole,  was  17  per  cent. 

The  diastolic  pressure  was  lowered  8  per  cent. 

The  pulse  pressure  was  decreased  24  per  cent. 

The  number  of  heart  beats  as  a  whole  were  decreased 


430  BLOOD-PRESSURE 

14  per  cent.  Fifty-six  patients  showed  a  decrease,  nine 
showed  an  increase  and  five  showed  no  change. 

If  we  examine  these  results  we  find  that  an  average 
lowering  for  all  cases  is  18  mm.  Hg.  The  average  lowering 
for  those  who  had  initial  pressures  ranging  between  140 
and  190  was  23  mm.  Hg. 

Those  individuals  who  had  a  low  initial  pressure  lowered 
only  7  mm.  Hg. 

For  instance,  one  fell  from  180  to  100;  another  from  170 
to  120;  another  from  190  to  115;  another  from  120  to  80; 
another  from  108  to  78,  etc.  It  is  in  these  extreme  results 
that  we  most  frequently  find  the  development  of  an  arrhy- 
thmia or  the  increase  of  an  arrhythmia  already  present. 

The  result  of  this  set  of  experiments,  supported  by 
the  clinical  fact  that  patients  with  diseased  hearts  may 
become  worse  on  brisk  catharsis,  warrants  the  assump- 
tion that  all  cases,  in  which  severe  purging  is  used  for  deple- 
tion of  the  blood,  ought  to  be  controlled  by  watching 
carefully  the  blood-pressure,  heart  rate  and  regularity,  and 
the  general  condition  of  the  patient. 

Salicylates. — All  salicylates  in  large  doses  reduce  blood- 
pressure  but  are  rarely  employed  for  this  effect,  although 
Hamburger^  recommends  their  use  for  this  purpose, 
basing  his  opinion  upon  the  results  of  experiments  with 
intravenous  and  hypodermatic  injections  of  sodium  sal- 
icylate in  dogs. 

Acetylsalicylic  Acid. — The  author  has  for  some  time 
employed  this  preparation  for  the  control  of  morning 
headaches  so  frequent  in  high-pressure  cases,  usually 
administering  5  gr.  upon  rising,  and  has  been  able  to  demon- 

^  Interstate  Med.  Jour.,  1911,  p.  667, 


VALUE    OF    DRUGS    AFFECTING   BLOOD-PRESSURE  431 

strate  to  his  satisfaction  that  not  only  are  these  head- 
aches controlled  with  this  minimum  dose,  but  a  continued 
reduction  in  systolic  pressure  is  obtained,  and  it  is  not 
usually  necessary  to  repeat  or  increase  this  dose. 

Strophanthus. — See  Digitalis. 

Strychnin. — There  has  been  considerable  controversy 
concerning  the  effect  of  strychnin  on  blood-pressure, 
although  MacKenzie  in  ''Diseases  of  the  Heart"  has 
held  that  this  drug  has  no  appreciable  effect  on  blood- 
pressure.  Recently  Wallace  and  Pemment^  after  a  careful 
investigation  of  the  effect  of  this  drug  upon  blood-pressure, 
conclude  that  in  approximately  normal  pressures  the 
drug  fails  to  produce  a  rise,  except  when  employed  in 
doses  too  large  to  be  considered  therapeutic.  In  artificially 
produced  low  pressures  they  obtained  the  following  results : 
After  chloral,  strychnin  hastens  the  return  to  normal 
level;  after  nitrites  there  is  no  appreciable  improvement; 
after  hemorrhage  there  is  no  effect;  after  diphtheria 
toxin  there  is  no  effect;  after  chloroform  no  effect;  after 
shock  by  traumatism  to  intestines  there  is  no  effect. 
They  conclude  from  this  series  of  experiments  that  the 
only  type  of  low  pressure  favorably  affected  by  strychnin 
is  that  following  depression  of  the  vasomotor  center,  such 
as  is  brought  about  by  chloral. 

Thiosinamin. — Lydston^  recommends  the  employment 
of  this  preparation  for  the  reduction  of  high  pressure  in 
which  relief  is  obtained  by  relieving  arterial  contraction, 
but  states  that  it  is  not  of  value  in  effecting  improvement 

1  G.  B.  Wallace  and  H.  C.  Pemment,  Jour.  A.  M.  A.,  July  20,  1912,  lix,  3, 
p.  218. 

2  G.  F.  Lydston,  Therap.  Gaz.,  July,  1912,  p.  466. 


432  BLOOD-PRESSURE 

through  alterations  in  structural  change.  The  dose  is 
/^  to  J^  gr.  three  times  a  day. 

Thyroid. — The  relation  of  the  ductless  glands  to  the 
maintenance  of  normal  blood-pressure  and  to  disturbance 
of  the  same,  through  abnormalities  in  internal  secretion, 
is  too  well  known  to  require  comment,  except  to  say  that 
it  has  been  repeatedly  pointed  out  that  a  deficiency  in 
thyroid  secretion  may  contribute  to  an  elevated  blood- 
pressure,  while  an  increase  in  adrenal  secretion  is  be- 
lieved to  have  the  same  effect,  and  that  signs  pointing  to 
such  abnormality  should  always  be  sought  for. 

Adminstration. — In  cases  of  high  pressure,  without 
excessive  cardiac  or  renal  involvement,  this  drug  may 
prove  of  great  service  in  reducing  and  maintaining  a  more 
normal  pressure  level.  It  has  also  been  found  of  value  in 
the  high  pressures  of  eclampsia.  Small  doses  of  the 
dried  gland,  1  to  3  gr.  per  day,  are  usually  as  efficient  as 
larger  doses,  and  large  doses  should  never  be  used,  nor 
the  drug  be  continued  for  a  long  period  of  time,  unless 
the  blood-pressure  and  pulse  rate  are  kept  under  close 
observation. 

Tobacco. — There  has  always  been  considerable  doubt 
as  to  whether  the  effects  ascribed  to  tobacco  were  due  to 
nicotin  or  to  other  substances.  The  majority  of  evidence 
indicates  that  nicotin  is  by  far  the  most  important,  if  not 
the  only  factor  concerned  in  elevating  blood-pressure, 
although  the  by-products  of  the  dry  distillation  of  tobacco, 
such  as  furfural  and  CO  must  be  reckoned  with.  Nicotin 
is,  next  to  adrenalin,  the  most  powerful  vasoconstrictor 
known.     Cook  and  Briggs^  have  shown  that  a  temporary 

*  Loc.  cil. 


VALUE    OF   DRUGS   AFFECTING   BLOOD-PRESSURE 


433 


rise  in  systolic  pressure  accompanies  smoking,  and  yet 
we  frequently  have  the  apparent  paradox  that  excessive 
smokers  often  have  a  low  systolic  pressure.  In  the 
habitual  smoker  (Fig.  90)  it  is  found  that  there  is  at  first 


Fig,  90. — Showing  the  effect  of  moderate  smoking  on  one  accustomed  to 
the  use  of  tobacco,  after  a  brief  period  of  abstinence.  Tracing  shows  very- 
well  the  sedative  effect  of  a  moderate  amoimt  of  tobacco,  and  the  pressure- 
raising  influence  of  several  cigars  smoked  in  rapid  succession.  Also  the 
general  downward  tendency  of  the  curve  would  suggest  that  the  individual 
became  gradually  reaccustomed  to  the  use  of  the  drug. 

an  increase  and  later  a  diminution  in  systoHc  pressure, 
the  latter  being  accompanied  by  that  sense  of  comfort  and 
relief  which  is  sought  by  the  habitual  user.  The  reduction 
in  pressure  following  the  use  of  tobacco  is  from  5  to  15 
mm.     From  the  experimental  standpoint,  it  does  not  appear 

28 


434  BLOOD-PRESSURE 

that  smoking  is  an  etiologic  factor  in  the  production  of 
arteriosclerosis,  at  least,  in  so  far  as  such  a  theory  presumes 
injury  to  the  vessels.^  The  use  of  tobacco  in  those  unac- 
customed to  it  is  often  accompanied  by  a  sharp  systolic 
rise. 

Vasotonin  {Urethan  and  Yohimbin). — Muller  and  Fellner,^ 
report  both  animal  experiments  and  clinical  observations 
of  the  effect  of  this  drug  on  blood-pressure.  They  con- 
clude that  its  effect  is  purely  that  of  peripheral  dilatation 
and  state  that,  while  the  drug  is  generally  used  abroad, 
the  results  so  far  in  this  country  have  not  been  uniform.^ 
One  of  the  most  valuable  effects  of  this  drug  is  said  to  be 
its  prolonged  action;  thus  the  subcutaneous  injection  of 
1  c.c.  is  usually  sufficient  to  reduce  blood-pressure  from 
20  to  40  mm.,  for  a  period  of  from  four  to  six  hours,  while 
if  given  for  several  successive  days  it  will  maintain  a  low- 
ered pressure  for  six  or  seven  days  thereafter. 

Veratrum  Viride. — This  drug  is  classified  with  the  heart 
depressants.  Its  chief  physiologic  action  is  upon  the 
circulation,  and  in  practice  it  is  used  chiefly  to  decrease  the 
force  of  the  heart.  It  is  ''a  prompt,  thoroughly  efficient, 
and  at  the  same  time  very  safe  remedy"  (Wood). 

In  chronic  cardiac  diseases  it  is  indicated  in  precisely 
those  cases  in  which  digitalis  is  contra-indicated.  The 
contra-indications  to  the  use  of  this  drug  are  cardiac  weak- 
ness and  general  adynamia.  When  used  in  excess  it  may 
cause  alarming  symptoms  which  simulate  shock,  but  even 
in  very  large  doses  it  is  seldom  fatal  (Wood).  In  this 
respect  it  is  far  less  dangerous  than  aconite.     Its  physio- 

1  Bruce,  Miller  and  Hooker,  Amer.  Jour.  Physiol,  April,  1909. 

2  Therap.  Mortal.,  1910,  xxiv,  p.  285. 

'  H.  D.  Arnold,  Boston  Med.  and  Surg.  Jour.,  18. 


VALUE    OF    DRUGS    AFFECTING    BLOOD-PRESSURE  435 

logic  effect  is  shown  in  a  slow  pulse  rate,  a  diminished 
force  of  the  heart's  action,  and  vasodilatation. 

Administration. — Fluidextract,  one  to  three  drops,  tinc- 
ture three  to  six  drops.  It  should  be  given  at  intervals  of 
two  or  three  hours,  when  continued  effect  is  desired,  and  its 
activity  may  be  hastened  by  gradually  increasing  the  dose 
until  the  physiologic  limit  is  reached.  In  some  cases 
annoying  vomiting  may  occur. 


CHAPTER  XXIV 

PHYSICAL  MEASURES  EMPLOYED  IN  THE  MANAGEMENT 

OF  CONDITIONS  PRESENTING  ABNORMAL 

BLOOD-PRESSURE 

Causes  of  Failure. — A  large  percentage  of  the  unsuccess- 
ful results  in  the  treatment  of  cardiovascular-renal  diseases 
can  be  traced  to  one  or  more  of  the  following  causes: 

1.  The  diagnosis  has  not  been  made  sufficiently  early. 

2.  The  case  may  have  been  carelessly  or  unskilfully 
studied. 

3.  The  predisposing  causes  have  not  been  found. 

4.  As  a  result,  the  condition  is  but  imperfectly  understood. 

5.  The  therapy  is  irrational  because  it  is  based  upon  an 
incomplete  knowledge  of  the  case  in  question,  plus  a 
deficient  knowledge  of  therapeutic  methods  by  drugs  or 
other  measures. 

6.  Too  great  dependence  has  been  placed  upon  drugs 
alone,  especially  the  vasodilators,  to  the  neglect  of  the 
newer  so-called  physiologic  methods. 

It  may  be  said  in  general  that  while  drugs  are  at  times 
invaluable  in  the  treatment  of  pathologic  circulatory 
conditions,  especially  in  emergency,  their  value  is  usually 
much  overestimated.  The  secret  of  successful  treatment 
usually  lies  in  a  careful  study,  an  early  and  complete 
diagnosis,  rigid  supervision  and  regulation  of  the  indi- 
vidual habits,  rather  than  attempts  to  lower  blood-pressure 
and  relieve  symptoms  by  the  employment  of  drugs.  A 
properly  conducted  study  will  sometimes  jdeld  gratifying 

436 


ABNORMAL   BLOOD-PRESSURE  437 

results  even  in  advanced  cases,  and  at  times  in  those  cases 
commonly  regarded  as  hopeless. 

The  most  satisfactory  results  naturally  follow  an  exhaus- 
tive examination  immediately  following  the  appearance 
of  the  first  suggestive  sign  or  symptom  of  impairment  of 
the  circulatory  apparatus.  This  should  be  followed  by  a 
careful  estimate  of  the  functional  power  left  in  the  impaired 
organs  and  the  immediate  adoption  of  a  life  and  habits 
suited  to  the  limitations  determined.  Thus  we  attempt 
to  produce  an  adjustment  of  the  individual's  manner  of 
life  which  will  give  an  equivalent  to  relative  good  health. 
By  ''correct  diagnosis"  the  broadest  meaning  of  this 
phrase  is  intended  and  not  the  mere  statement  that  the 
patient  has  "cardiovascular-renal  disease." 

To  arrive  at  a  correct  diagnosis,  one  must  take  a  full 
history,  including  a  complete  analysis  of  social  history  and 
personal  habits,  carefully  considering  both  business  and 
social  activities,  making  a  comprehensive  physical  examina- 
tion, including  blood  and  urine  examinations,  and  taking 
the  blood-pressure,  not  omitting  the  functional  tests.  In 
fact  the  success  of  treatment  depends  primarily  upon 
the  completeness  in  which  each  problem  is  studied  and 
upon  the  intelligence  with  which  the  remedies  are  employed 
and  only  in  a  minor  degree  upon  the  particular  remedial 
measures  applied. 

Direct  therapeutic  measures  aimed  at  distinct  pathologic 
conditions  will  not  be  considered,  as  they  are  beyond  the 
object  and  scope  of  this  book.  This  chapter  will  consist 
more  of  a  r^sum^  of  existing  literature  and  mil  be  more 
in  the  nature  of  a  reference  chapter  to  be  consulted 
when  knowledge  of  the  relative  value  of  certain  measures 


43S  BLOOD-PRESSURE 

and  information  concerning  the  effect  of  any  particular 
drug  is  desired. 

PHYSICAL  MEASURES 

Under  the  head  of  physical  measures  valuable  in  con- 
trolling and  in  reducing  high  pressure,  we  find: 

Rest. 

Exercise. 

Massage. 

Diet. 

Hydrotherapy. 

Electrotherapy. 

Venesection. 

Rest  and  Posture. — Preeminently  rest  is  the  first  essential 
in  the  treatment  of  all  cardiovascular  and  renal  conditions. 
It  is  safe  and  beneficial  to  begin  every  course  of  treatment 
by  rest.  The  term  rest  as  here  used  may  be  purely  relative 
or  may  mean  absolute  recumbency.  The  degree  of  rest 
enforced  will  depend  on  the  physician's  judgment  as 
based  upon  experience  and  the  extent  of  his  knowledge  of 
the  case  and  its  requirements;  no  set  rule  can  be  adhered 
to  blindly. 

In  the  cases  suddenly  developing  signs  of  incompe- 
tency, with  dyspnea,  a  large  heart,  venous  congestion,  etc., 
the  decision  is  obvious;  absolute  rest  and  mental  relaxa- 
tion are  imperative — nothing  else  will  do.  First  and 
foremost,  all  unnecessary  strain  must  be  removed  from  the 
overburdened  and  dilated  heart.  This  alone  may  suffice 
to  break  the  vicious  circle,  allow  the  heart  muscle  to 
regain  its  lost  tone  and  so  pave  the  way  for  a  period  of 
at  least  relative  health. 


ABNORMAL  BLOOD-PRESSURE  439 

Rest  in  bed  will  alone  often  be  sufficient  to  reduce  a 
dangerously  high  blood-pressure.  I  have  repeatedly- 
seen  a  pressure  of  over  200  mm.  fall  to  and  maintain  a 
new  level  of  from  15  to  25  mm.  lower.  Occasionally 
even  a  greater  reduction  than  this  will  be  effected  by  this 
measure. 

Effects  of  Sleep  and  Rest  on  Blood-pressure. — Brooks 
and  Carroll^  studied  this  question  in  sixty-eight  patients 
showing  average  systolic  pressure,  in  thirty  with  low  pres- 
sures and  in  twenty-nine  with  abnormally  high  pressures. 
The  results  are,  in  a  general  way,  illustrated  in  the  cases 
with  average  pressure,  in  which  readings  taken  between  one 
and  two  hours  after  the  beginning  of  sleep  showed  an 
average  drop  of  24  mm.  Hg.  For  three  hours  after  awak- 
ening in  the  morning  there  was  still  an  average  depression 
of  12  mm.  and  from  this  time  onward  the  pressure  gradually 
rose  until  usual  highest  level  was  reached  in  the  afternoon. 
The  greatest  nocturnal  fall  in  pressure  took  place  in  those 
individuals  having  the  highest  initial  systolic  reading. 
Disturbance  of  patients  during  the  first  sleep  was  found  to 
delay,  but  not  necessarily  prevent,  the  maximal  fall  in 
pressure;  frequent  interruption  did,  however,  prevent  it. 
Special  tests  were  made  to  determine  whether  the  sleep 
drop  could  be  artificially  increased  in  order  to  secure  a 
lower  general  pressure  curve  in  cases  of  hypertension; 
potassium  bromid  in  doses  as  high  as  120  gr.,  and  chloral 
hydrate  up  to  50  gr.  each  night  were  not  found  to  in- 
crease the  degree  or  persistence  of  the  fall.  Physical  rest 
in  general  did  not  appear  to  alter  materially  either  super- 
normal or  normal  blood-pressure,  but  Brooks  and  Carroll 

^  Archives  of  Int.  Med.,  August,  1912. 


440  BLOOD-PRESSURE 

were  led  to  believe  that  in  mental  or  psychic  rest  pro- 
found changes  in  pressure  occur,  and  that  this  factor 
largely  determines  the  undoubted  benefit  derived  from 
rest  in  cases  of  high  pressure. 

Exercise. — In  certain  cases,  particularly  those  of  the 
active  business  and  professional  men,  it  is  not  more  rest 
but  more  exercise  that  is  needed.  These  are  the  cases  in 
which,  if  seen  sufficiently  early,  much  may  be  accomplished 
toward  permanently  arresting  the  trouble,  provided  of 
course  that  the  patient  is  ready  and  willing  to  assume  a 
new  rule  of  life.  They  probably  belong  among  those 
classed  as  true  hypertonus,  with  tonic  contraction  of  the 
circular  fibers  of  the  arteries  (see  page  244),  with  but  little 
or  no  permanent  pathologic  change,  the  kidneys  showing 
only  signs  of  irritation.  Under  these  conditions  complete 
relief  often  follows  a  carefully  regulated  diet,  combined 
with  an  increased  amount  of  daily  exercise,  which  should 
not  be  begun  suddenly,  nor  be  very  strenuous;  walking 
first,  to  be  followed  later  by  light  gymnastics  or  golf. 
Such  measures  should  always  be  carefully  followed  by 
sphygmomanometer  tests. 

In  institutions  and  hospitals  devoted  to  the  treatment 
of  chronic  cardiovascular  and  renal  diseases  the  exercise 
methods  of  Schott  and  Ortel,  under  competent  supervision 
and  proper  guidance,  accomplish  much  good  by  educating 
the  heart  muscle  to  withstand  added  strain  and  by  improv- 
ing cardiomuscular  tonus.  It  is  not  advisable  that  the 
general  practitioner,  seeing  but  few  cases,  should  attempt 
these  special  exercise  treatments,  as  they  need  specialized 
attention.  However,  much  can  be  accomplished  by  sys- 
tematized walking. 


ABNORMAL   BLOOD-PRESSURE  441 

Massage. — General  massage  is  usually  well  borne  and 
is  of  value  in  the  treatment  of  cases  showing  failing  com- 
pensation or  defective  heart  tone.  Massage  acts  by  empty- 
ing the  venous  side  of  the  circulation  and  so  relieves  the 
left  side  of  the  heart;  it  also  dilates  the  superficial  capillaries, 
thereby  aiding  in  the  distribution  of  the  blood.  Massage 
of  the  chest  may  influence  favorably  the  tone  of  the  heart 
itself,  but  deep  pressure  upon  the  abdomen  should  be 
avoided  in  order  to  escape  a  rise  in  blood-pressure  and 
all  movements  should  be  graded  to  the  strength  of  the 
individual. 

Both  Eichberg^  and  A.  Strausser^  advocate  the  employ- 
ment of  massage  in  the  treatment  of  cardiovascular  dis- 
eases, and  Eichberg  has  shown  that  massage  movements, 
even  if  prolonged,  do  not  effect  a  rise  in  blood-pressure. 

Dietetics. — Much  has  been  said  and  many  dietetic 
outlines  have  been  advocated  in  the  treatment  of  circu- 
latory disturbances.  Their  chief  object  is  to  diminish 
nitrogenous  intake,  to  reduce  putrefactive  changes  in  the 
intestines  which  produce  auto-intoxication,  and  to  relieve  the 
strain  on  a  dilated  and  defective  heart  muscle  by  reducing 
dangerously  high  pressure  through  limiting  the  fluid  intake 
which  eventually  modifies  the  total  amount  of  fluid  in  the 
body. 

Foods. — A  safe  general  rule  to  follow  is,  that  while 
nitrogenous  food  is  not  prohibited,  the  amount  should  be 
greatly  reduced,  and  a  vegetable,  farinaceous  and  milk  diet 
substituted. 

An  absolute  milk  diet  cannot  be  continued  over  a  long 

^Jour.  A.  M.  A.,  Sept.  19,  1908. 

2  Wien.  med.  Wochen.,  Apr.  8-15,  1909. 


442  BLOOD-PRESSURE 

period  because  it  is  impossible  to  give  sufficient  nourish- 
ment without  seriously  overstepping  a  safe  maximum  of 
fluid  ingestion,  excessive  fluid  sometimes  being  a  factor  in 
the  production  of  high  blood-pressure. 

A  short  period  of  absolute  milk  (2  quarts)  is  useful  for 
the  relief  of  certain  symptoms,  and  may,  if  guarded,  be 
employed  with  benefit.  It  should  be  given  at  two-  or 
three-hour  periods  and  never  in  large  quantities  at  one 
time.  The  addition  of  some  flavoring  or  prepared  junket 
renders  the  milk  diet  less  irksome  to  the  patient. 

In  the  treatment  of  cardiovascular  cases  the  best  results 
generally  follow  light  meals  taken  at  frequent  intervals 
(three  to  three  and  one-half  hours).  This  prevents  possi- 
ble harm  from  the  throwing  of  heavy  strain  on  the  heart  and 
blood-vessels  through  the  digestive  apparatus,  which  might 
easily  disturb  a  poorly  balanced  circulatory  equilibrium. 

Alcohol,  tea  and  coffee  are  usually  prohibited,  at  least  for 
a  time.  An  exception  to  this  would  perhaps  be  a  heavy 
drinker,  whose  habitual  potations  should  not  be  suddenly 
and  entirely  interdicted.  As  a  substitute  for  coffee,  postum 
may  be  employed;  and  recently  a  patented  process  has 
been  used  in  Germany  by  which  the  coffee  bean  is  freed  of 
90  per  cent,  of  its  caffein.  The  taste  of  the  coffee  is  not 
materially  changed,  but  the  effect  upon  the  heart  and  blood- 
vessels is  decidedly  lessened.  Eisner^  and  others  report 
the  use  of  this  preparation  during  a  period  of  several  years 
to  their  satisfaction. 

Tobacco. — Tobacco  in  the  form  of  pipe,  cigarettes  and 
cigars  has  the  power  of  raising  blood-pressiu-e,  with  the 
seeming  paradox  that  the  habitual  smoker  has  ordinarily 

^  Boston  Med.  and  Surg.  Jour.,  No.  7,  1910. 


ABNORMAL   BLOOD-PRESSURE  443 

a  low  pressure.  Arterial  disease  tends  to  augment  the 
effect  of  smoking  on  arterial  pressure.  It  is  often  a  point 
of  delicate  decision  to  determine  the  amount  of  harm  result- 
ing from  the  use  of  tobacco,  and  the  proper  restriction  in 
the  use  of  the  drug  necessary  in  each  particular  case. 
When  in  doubt  the  best  rule  is  to  regulate  the  patient's 
habits,  with  due  regard  to  special  idiosyncrasies.  In 
cases  with  a  history  of  anginoid  attacks,  tobacco  in  all 
forms  should  be  prohibted  entirely.^ 

The  habit  of  chewing  tobacco  is  much  more  harmful  than 
smoking  because  of  the  greater  amount  of  active  principle, 
nicotin,  which  enters  the  system.    It  should  not  be  tolerated. 

In  restricting  diet,  no  definite  rule  can  be  laid  down 
which  can  be  followed  safely  in  every  case.  Each  case  has 
its  own  peculiarities  and  the  physician  should  endeavor 
to  determine  the  restrictions  to  be  made,  and  what  things 
may  be  allowed  with  safety  in  a  given  case.  One  should 
be  careful  in  any  dietetic  scheme  to  avoid  a  caloric  reduc- 
tion below  the  needs  of  the  individual,  otherwise  much 
harm  may  be  done,  for  it  is  impossible  to  build  up  a  strong 
heart  upon  insufficient  nourishment, 

L.  F.  Bishop-  makes  the  following  suggestions  which 
may  serve  as  a  valuable  guide  in  the  preparation  of  a 
diet  list  in  hypertension  and  chronic  heart  disease. 

First,  he  suggests  that  every  student  of  the  subject 
should  address  the  Superintendent  of  Documents,  Govern- 
ment Printing  Office,  Washington,  D.  C,  enclosing  ten 
cents  and  asking  for  Bulletin  No.  28  on  the  '^  Chemical 
Composition  of  American  Food  Materials." 

^  A.  Strausser,  Wien.  klin.  Wochen.,  Apr.  15,  1909. 
2  N.  Y.  Med.  Jour.,  Mar.  4,  1911. 


444  BLOOD-PRESSURE 

Second,  the  principle  to  be  remembered  is  that  an 
adult  required  from  14  to  20  calories  per  pound,  body 
weight,  proportional  to  his  physical  activities,  the  weight 
to  be  estimated  by  the  normal  weight  for  the  height  of  the 
individual.  For  example,  a  person  5  ft.  7  in.  tall  ought  to 
weigh  150  lb.;  at  light  work  he  will  require  an  average  num- 
ber of  heat  units  per  pound  17,  150  X  17  =  2550  calories. 
If  a  healthy  man  averages  more  than  this,  he  will  accu- 
mulate fat;  if  he  has  less  he  will  become  run  down,  and  a 
weak  heart  cannot  be  built  up  on  insufficient  nutrition. 

Bishop  submits  the  following  dietary  covering  a  period 
of  five  days,  which  allows  a  fair  caloric  intake: 

Diet 

Calories  Protein 

Luncheon: 

1  cup  of  bouillon 40                      10 

2  slices  of  mushroom  on  toast 50                        2 

1  tablespoon  of  potatoes 100                     2 

1  plate  of  endive  and  lettuce  salad 125  (oil) 

1  saucer  of  rhubarb. 

1  piece  of  gingerbread 230  4 

Dinner: 

1  plate  of  vegetable  soup 50  3 

3  tablespoons  of  stewed  tomatoes. 

1  large  tablespoon  of  potatoes 110  2 

2  large  tablespoons  of  beans 60  4 

2  tablespoons  of  Indian  pudding 175  8 

Lactose  with  each  meal 300 

Average  breakfast 315  8 

Total  for  day 1565  43 

January  21. 
Breakfast: 

1  orange 40 

1  small  bowl  of  wheat  berries 160  4 

2  slices  of  toast 115  4 

1  cup  of  weak  coffee. 


ABNORMAL   BLOOD-PRESSURE  445 


Luncheon: 


4  large  fried  scallops 60                     8 

2  tablespoons  of  creamed  potatoes 220                     4 

1  plate  of  cabbage  and  lettuce  salad 125  (oil) 

2  tablespoons  of  preserved  peaches 40 

1  cup  of  weak  tea. 

Dinner: 

1  plate  of  vegetable  soup 50                     3 

3  small  slices  of  bread 230                      8 

2  tablespoons  of  potatoes 220                      4 

2  tablespoons  of  spinach. 

1  plate  of  scallop  and  lettuce  salad 140                      4 

1  small  piece  of  pumpkin  pie 250                      4 

1  small  piece  of  cheese 120                      8 

Lactose  with  each  meal 300 

Total  for  day 2070                    51 

January  22. 

Breakfast,  practically  as  before 315                     8 

Dinner: 

1  plate  of  vermicelli  soup 120                     4 

4  small  potatoes 200                      4 

2  tablespoons  of  gravy. 

3  stewed  onions 100                     4 

Ice  cream 320                     8 

Cake 230                     4 

3  small  slices  of  bread 230                     8 

Tea:  i 

1  cup  of  bouillon 40                   10 

1  tablespoon  of  fried  potatoes 110                     2 

3  slices  of  bread 238                      8 

1  plate  of  lettuce  and  celery  salad 125  (oil) 

1  cup  of  weak  tea. 

Ice  cream .- . .  .  320                      8 

Sponge  cake 230                      4 

Lactose  with  each  meal 300 

Total  for  day 2870                   72 


446  BLOOD-PRESSURE 

January  23. 

Breakfast,  as  before 315                      8 

Luncheon: 

3  tablespoons  of  macaroni 100                     3 

2  tablespoons  of  spinach. 

3  small  slices  of  bread 230                      8 

1  plate  of  lettuce  and  endive  salad 125  (oil) 

1  piece  of  pumpkin  pie 250                      4 

2  pieces  of  cheese 120                     8 

1  cup  of  weak  tea. 

Dinner: 

Large  plate  of  farina  soup 50                      2 

3  tablespoons  of  macaroni 100                      3 

2  tablespoons  of  potatoes 220                      4 

3  pieces  of  preserved  peaches 40 

3  slices  of  bread 230                      8 

Lactose  with  each  meal 300 

Total  for  day 2080                    48 

January  24. 

Breakfast,  as  before 315                      8 

Luncheon: 

1  plate  of  lettuce  and  endive  salad 125  (oil) 

2  tablespoons  of  potatoes 220                      4 

2  tablespoons  of  fried  hominy 120                      4 

3  pieces  of  preserved  peaches 40 

1  cup  of  weak  tea. 


Dinner: 


Large  plate  of  vegetable  soup 50  3 

2  tablespoons  of  boiled  potatoes 180  4 

2  tablespoons  of  stewed  peas 100  7 

2  tablespoons  of  rice  pudding 175  4 

Lactose  with  each  meal 300 

Total  for  day 1625  34 

N.  B. — One  glass  Sauterne  with  each  luncheon. 
Average  for  five  days:  Protein,  49;  calories,  2.040. 


ABNORMAL   BLOOD-PRESSURE  447 

Roughly  speaking  the  average  helping  of  meat  contains 
25  gm.  of  proteid,  an  egg  contains  8  gm.,  as  does  also  a 
glass  of  milk.  An  ordinary  helping  of  rice,  potatoes,  bread 
or  hominy  contains  about  4  gm.,  thick  cream,  butter  and 
oil  contain  practically  no  proteid,  but  are  very  rich  in  heat 
units.  Green  vegetables  do  not  count  one  way  or  the 
other.  In  cardiovascular  disease,  milk  sugar  is  a  valuable 
addition  to  diet,  for  many  reasons.  A  sufficiency  of 
calories  can  be  roughly  judged  by  watching  the  weight; 
if  the  weight  is  maintained  the  caloric  supply  is  sufficient. 

Water. — Water  properly  employed  may  be  of  great  value 
in  the  treatment  of  cardiovascular  and  renal  diseases,  but 
like  any  other  good  thing,  it  can  be  overworked.  Cases 
are  on  record  where  apparently  the  only  causative  factor 
in  the  production  of  chronic  interstitial  nephritis  was 
continued  excessive  water  drinking.  Usually  it  is  advisable 
to  limit  the  amount  of  water,  especially  in  extreme  high- 
tension  cases  or  where  there  is  a  tendency  to  edema,  for 
this  will  spare  both  the  heart  and  blood-vessels,  but  the 
amount  should  not  be  reduced  below  1500  c.c.  per  day. 
Even  when  there  is  edema,  the  reduction  of  water  should 
not  be  continued  for  more  than  three  consecutive  days 
below  this  figure  (A.  Strausser). 

HYDROTHERAPY 

As  before  stated,  the  functional  capacity  of  the  heart 
depends  entirely  upon  the  condition  of  the  heart  muscle  and 
not  in  the  shghtest  degree  upon  disease  of  the  valves. 
So  in  the  therapeutics  of  chronic  heart  disease,  estimation 
of  the  integrity  of  the  muscle  is  of  first  importance  as  our 


448  BLOOD-PRESSURE 

chief  aim  is  to  restore  that  muscle  as  near  as  possible  to  its 
functional  integrity. 

Hydrotherapy  in  the  treatment  of  high  blood-pressure, 
particularly  accompanied  by  arteriosclerosis,  accomplishes 
its  result  chiefly  through  regulation  of  the  circulation. 
Properly  used,  such  methods  may  under  certain  conditions 
check  the  progress  of  disease  by  breaking  the  vicious 
circle  in  which  the  patient  is  involved.  The  primary  effect 
of  plain  water,  either  hot  or  cold,  applied  to  the  surface 
of  the  body,  has  been  found  by  most  observers  to  cause  an 
initial  rise  in  blood-pressure. 

This  elevation  usually  amounts  only  to  a  few  millimeters 
and  is  followed  speedily  by  a  reaction,  accompanied  by 
lower  pressure,  due  to  a  relaxation  of  hypertonus  and 
diminished  peripheral  resistance,  resulting  in  an  increased 
flow  of  blood  through  the  capillaries. 

Cold  Baths. — A  cold  shower  constricts  the  skin  and  lowers 
the  axillary  and  mouth  temperatures  to  normal  or  sub- 
normal. The  pulse  is  reduced  in  frequency  but  increased 
in  volume  and  the  blood-pressure  is  elevated.  The  breath- 
ing volume  and  alveolar  tension  is  increased. 

The  application  of  cold  to  the  precordium  is  immediately 
followed  by  a  rise  in  the  systolic  pressure.  ^ 

The  careless  application  of  cold  to  high-pressure  cases 
may  be  dangerous.  The  effect  should  first  be  ascertained 
by  rubbing  cold  water  c^er  portions  of  the  body.  Cold 
applications  can  only  be  used  with  safety  in  early  arterio- 
sclerosis and  cold  douches  should  be  used  with  extreme 
caution,  as  they  do  not  as  a  rule  give  as  good  results  as 
rubbing  or  ordinary  bathing.     Cold  sea-water  baths  should 

^  Hirchfeld  and  Lewin,  Zeitsch./.  Physiol,  u.  Diet.  Therap.,  No.  1,  1914. 


ABNORMAL   BLOOD-PRESSURE  449 

not  be  indulged  in  by  arteriosclerotics  nor  by  those  having 
myocardial  degeneration. 

The  Scottish  douche  (alternate  application  of  hot  and 
cold  water)  frequently  gives  good  results  in  hypertension, 
provided  the  contrast  between  the  temperatures  employed 
is  properly  graduated. 

Hot  Baths.— A  full  hot  bath  (105  to  110°F.)  raises  the 
mouth,  axillary  and  rectal  temperatures  and  is  accom- 
panied by  an  increased  pulse  frequency  (up  to  160) 
and  a  lowered  systolic  pressure.  The  rise  in  body  tem- 
perature is  accompanied  by  greatly  increased  respiratory 
frequency  and  breathing  volume,  and  is  accompanied  by  a 
notable  fall  in  carbon-dioxid  tension,  and  a  corresponding 
rise  in  the  oxygen  tension  of  the  alveolar  air.^ 

Because  of  the  constant  and  fairly  uniform  reduction  in 
systolic  blood-pressure  accompanying  the  hot  bath,  it  is 
believed  to  be  a  reliable  adjunct  in  the  treatment  of  many 
of  the  chronic  diseases  in  which  there  is  high  blood-pressure. 
It  also  acts  as  a  powerful  diaphoretic  and  this  action 
seems  to  be  of  some  value  in  these  cases. ^  According  to 
Hirchfeld  and  Lewin^  the  application  of  local  heat  causes 
a  rise  in  systolic  pressure. 

The  temperature  of  hot  baths  in  cases  of  arteriosclerosis 
should  not  exceed  37  or  38°C.  Extreme  changes  in  tem- 
perature of  baths  is  also  contra-indicated  in  arteriosclerosis, 
because  of  the  danger  in  any  sudden  change  in  pressure, 
particularly  any  sudden  increase  arising  from  capillary 
contraction  which  causes  increased  peripheral  resistance. 

^Leonard  Hill  and  Morton  Flack,  Jour.  Physiol.,  xxviii,  p.  441,  1909. 
2  C.  L.  Palmer,  Penna.  Med.  Jour.,  March,  1915,  xviii,  6. 
'  Loc.  cit. 
29 


450  BLOOD-PRESSURE 

Hot-air  baths  and  electric-light  baths  are  probably  as 
good  as  the  direct  application  of  hot  water,  and  should  be 
employed  whenever  practical. 

In  the  high  blood-pressure  accompanying  acute  nephritis, 
with  the  usual  subjective  symptoms,  I  have  seen  great  bene- 
fit follow  a  properly  given  electric-light  bath,  the  tempera- 
ture being  allowed  to  rise  in  the  cabinet  to  125°F.  where  it  is 
maintained  for  from  fifteen  to  twenty  minutes.  Under 
these  circumstances  an  immediate  fall  in  pressure  occurs, 
often  amounting  to  from  15  to  30  mm.,  occasionally  more, 
and  this  fall  is  usually  lasting  in  character,  often  persist- 
ing for  twenty-four  hours.  The  effect  upon  the  patient  is 
most  satisfactory,  the  subjective  signs  immediately  subsid- 
ing. Elimination  is  increased  while  the  pathologic  elements 
in  the  urine  are  diminished. 

The  proper  administration  of  an  electric-light  bath  de- 
pends upon  the  intelligent  use  of  the  sphygmomanometer. 
By  this  instrument,  and  by  its  aid  alone  can  the  immediate 
effects  of  the  bath  be  measured,  so  that  the  duration  and  the 
period  of  administration  may  be  definitely  calculated. 
Hydrotherapeutic  measures  sometimes  accomphsh  good 
results  when  drug  medication  absolutely  fails.  This  was 
well  shown  in  one  case,  where  nitroglycerin  was  given  to 
the  point  of  intolerance,  without  effect  upon  blood-pressure, 
while  the  electric-hght  bath  speedily  reduced  the  pressure 
and  easily  maintained  a  reduction  of  45  mm. 

Miller  recently  has  reported  a  practical  series  of  clinical 
studies  on  the  effect  of  the  sweating  process  in  high-pressure 
cases.  In  his  series  all  patients  reported  sweated  profusely 
for  at  least  thirty  minutes.  The  methods  of  producing  the 
sweat  varied.     The  blood-pressure  was  taken  just  before 


ABNORMAL   BLOOD-PRESSURE  451 

the  sweat  ceased.  Three  out  of  five  cases  showed  a  reduc- 
tion in  pressure  ranging  from  13  to  20  mm.  In  one  case 
it  did  not  return  to  previous  level  until  a  lapse  of  four  hours. 
Patients  always  felt  better  after  the  sweating.  Dyspnea 
(uremic)  is  generally  relieved  even  when  the  pressure  is  not 
reduced. 

A  number  of  patients  were  given  one  or  more  daily  sweats 
for  two  or  three  weeks,  the  pressure  recorded  daily;  results 
varied,  in  some  there  was  no  change,  some  showed  a  gradual 
fall.  One  case  which  had  been  over  210  for  several  years, 
came  down  to  180. 

In  chronic  cases  the  sweating  process  is  not  lasting  in  its 
efifect,  as  the  pressure  soon  returns  to  original  level  when 
sweats  are  discontinued.  Poststernal  oppression  is  relieved 
more  often  by  sweats  than  by  other  measures. 

Effect  of  Sweating  on  Blood-pressure  (Miller) 


Case 

Blood-pres- 
sure before 
sweating 

Blood-pres- 
sure after 
sweating 

1 

160 

140 

Four  hours  before  it  reached  previous  level. 

2 

190 

190 

3 

170 

170 

4 

190 

175 

Two  hours  before  it  reached  previous  level. 

5 

185 

172 

The  sudden  application  of  cold  or  chilling  after  a  sweat  is 
dangerous.  In  one  case  Miller  has  reported  a  rise  of  60 
mm.,  followed  by  transitory  numbness.  Over-reduction  of 
pressure  may  be  followed  by  untoward  results,  although 
this  does  not  always  follow. 

The  Nauheiin  Treatment. — There  is  no  method  of  de- 
termining in  advance  the  particular  effect  of  any  special 
hydrotherapeutic  measure.     This  applies  to  low-pressure 


452  BLOOD-PRESSURE 

cases  as  well  as  to  those  with  a  high  initial  pressure, 
so  that  the  relief  of  subjective  symptoms  in  cases  of  heart 
disease  is  not  necessarily  dependent  upon  the  influence  of 
the  baths  upon  blood-pressure.  The  basis  of  the  Nauheim 
treatment  in  circulatory  disorders  is  rest,  hydrotherapeutic 
measures  and  exercise.  Its  chief  value  in  the  treatment  of 
circulatory  disorders  comes  from  its  effect  on  the  heart 
muscle.  Acting  upon  the  heart,  it  increases  tonus  and 
reduces  dilatation.  Acting  upon  the  circulation,  it  dilates 
the  arterioles  and  capillaries,  thereby  relieving  a  high  peri- 
pheral resistance  and  obtaining  a  more  uniform  distribution 
of  blood.  These  baths  do  not  always  produce  a  reduction 
in  blood-pressure,  and  they  may  be  followed  by  disastrous 
results.  In  this  connection  it  is  important  to  sound  a 
warning  note.  Neither  the  oxygen  nor  the  CO2  bath 
should  be  used  without  a  working  knowledge  both  of 
what  is  desired  and  what  such  treatment  may  be  expected 
to  accomplish. 

Application. — The  chief  hydrotherapeutic  method  em- 
ployed at  Nauheim  is  the  complete  immersion  of  the 
patient  in  a  bath  of  natural  brine,  which  is  charged  with 
free  CO2  gas.  The  most  important  constituents  of  this 
bath  are  sodium  chlorid  and  calcium  chlorid.  The  tem- 
perature of  the  bath  is  varied  according  to  experience.  The 
patient  remains  immersed  for  a  period  of  from  four  to  fifteen 
minutes,  is  then  carefully  dried,  without  chilling,  and  re- 
quired to  rest  in  bed  for  an  hour.  The  baths  are  given  on 
alternate  days;  the  course  usually  occupies  six  weeks. 
Baths  of  similar  character  are  given  under  medical  super- 
vision at  Glen  Springs,  N.  Y.,  where  the  methods  are  much 
the  same  as  those  at  Nauheim  and  the  benefits  derived 
probably  as  great. 


ABNORMAL  BLOOD-PRESSURE  453 

According  to  Dr.  John  M.  Swan/  formerly  of  Glen 
Springs,  the  effects  to  be  expected  from  the  proper  use  of 
carbonated-brine  baths  are  as  follows : 

1.  Diminution  of  the  size  of  the  heart. 

2.  Slowing  of  the  pulse. 

3.  Reddening  of  the  skin. 

4.  Slowing  of  the  respiration. 

5.  Reduction  in  the  size  of  the  liver,  if  that  organ  has 
been  the  seat  of  passive  congestion. 

6.  Improvement  in  the  muscular  quality  of  the  heart  sounds. 

7.  The  disappearance  of  hemic  murmurs,  or  those  due 
to  dilatation  of  an  orifice. 

8.  Increase  in  the  intensity  of  those  murmurs  which  are 
dependent  on  valvular  defect  or  deformity. 

The  chief  indication  for  the  use  of  the  carbonated-brine 
bath  in  the  treatment  of  chronic  heart  disease  is  in  cases  of 
myocardial  weakness,  with  low  pressure.  In  such  cases 
we  expect  to  get  a  retarding  of  the  pulse,  an  improved 
heart-muscle  sound  and  a  rise  in  blood-pressure. 

In  cases  of  senile  heart,  with  high  blood-pressure  and 
evidence  of  general  arteriosclerosis,  carbonated-brine  baths, 
if  given  at  all,  should  be  stopped  upon  the  development 
of  an  increase  in  blood-pressure,  whether  shown  by  sub- 
jective symptoms,  or  by  the  sphygmomanometer.  In 
cases  where  the  beneficial  effect  of  the  bath  is  in  doubt, 
danger  may  be  avoided  if  the  temperature  of  tjie  bath  is 
kept  above  98°F.,  or  else  the  strong  brine  should  be  omitted 
or  diluted,  and  the  CO2  gas  left  out.  According  to  Swan, 
CO2  baths  are  contra-indicated  in  cases  of  advanced  arterio- 
sclerosis, chronic  nephritis,  aneurism  of  the  large  arterial 

^Interstate  Med.  Jour.,  June,  1911,  xviii,  6. 


454  BLOOD-PRESSURE 

trunks,  and  in  the  terminal  stages  of  broken  compensation 
with  edema. 

After  the  diseased  myocardium  has  had  an  opportunity 
to  recuperate,  and  to  regain  some  of  its  lost  tone  by  rest 
and  the  bath  treatment,  it  is  often  advisable  to  provide 
exercise  under  proper  supervision  in  order  to  help  the  heart 
perform  its  normal  functions  in  as  nearly  a  normal  fashion 
as  possible.  This  is  in  the  nature  of  a  special  training  of  the 
muscles  to  be  developed.  Two  systems  have  been  devised 
which  apply  graduated  work  to  the  heart:  first,  Schott 
method  or  resistance  movement;  and,  second,  Ortel  method 
of  graduated  hill  climbing.  These  consist  of  a  number  of 
exercises  of  increasing  severity,  arranged  so  that  the 
increased  work  imposed  on  the  heart  is  very  slight,  but  is  in- 
creased in  proportion  as  the  heart  muscle  learns  to  bear  the 
strain.  For  more  complete  descriptions  of  these  methods 
and  their  application,  the  reader  is  referred  to  works  devoted 
to  hydrotherapy  and  the  treatment  of  heart  diseases. 

Oxygen  Bath. — A  mode  of  treatment  that  has  recently 
been  advocated  and  favorably  reported  upon  by  a  number 
of  observers  is  the  oxygen  bath.  According  to  reports  the 
effect  of  the  oxygen  bath  is  very  different  from  that  of  the 
CO2.  In  the  CO2  bath  the  skin  becomes  reddened  from 
dilatation  of  the  superficial  vessels,  while  in  the  oxygen 
bath  the  cutaneous  vessels  are  constricted  and  the  skin 
becomes  pale.  The  oxygen  bath  at  95°F.  reduces  both 
pulse  rate  and  blood-pressure,  while  the  effect  of  the  CO2 
bath  upon  blood-pressure  is  variable.  In  arteriosclerosis 
these  baths  are  said  to  be  beneficial,  resulting  among  other 
things  in  a  moderate  reduction  of  blood-pressure.  Accord- 
ing to  the  conclusions  of  A.  Wolfe^  the  respective  effects  of 

1  Zeilsch.f.  Physiol,  u.  Viet.  Therap.,  Vol.  xiv,  191Q, 


ABNORMAL   BLOOD-PRESSURE  455 

the  oxygen  and  the  CO2  bath  upon  the  human  body  are  as 
follows : 

1.  The  temperature  of  the  water  in  both  instances  has  a 
material  bearing  upon  its  influence  on  blood-pressure. 

2.  At  93  or  94°F.  neither  bath  has  much  influence  on 
blood-pressure  if  this  be  not  pathologically  changed.  The 
CO2  bath  at  94°  tends  primarily  to  increase  a  pathologic 
blood-pressure,  whether  this  was  at  first  a  hypo-  or  a 
hypertension. 

3.  The  normal  pulse  is  but  little  altered  by  either  bath, 
while  the  CO2  reduces  it  more  often  in  less  degree  than  the 
oxygen  bath,  when  the  pulse  is  originally  abnormal. 

In  employing  the  oxygen  bath,  the  patient  should  not 
enter  it  immediately  after  active  exercise  or  mental  excite- 
ment, and  unnecessary  movement  should  be  avoided  while 
in  the  bath.  He  should  be  carefully  dried  and  then  should 
immediately  lie  down  for  an  hour.  The  duration  of  the 
bath,  depending  upon  the  effect  desired,  should  be  from 
ten  to  twenty-five  minutes,  and  should  be  given  on  alter- 
nate days.  The  bath  is  contra-indicated  in  low  blood-pres- 
sure accompanying  the  last  stages  of  arteriosclerosis.  Also 
for  those  with  mitral  defects  or  marked  anemia. 

The  ingredients  for  the  oxygen  bath  (sodium  perborate 
and  magnesium  borate)  can  be  obtained  in  the  open 
market  under  the  name  of  ^'perogen"  bath. 

ELECTROTHERAPY 

Much  has  been  said,  and,  if  possible,  more  has  been 
written,  upon  the  subject  of  electrical  treatment  for  the 
reduction  of  arterial  hypertension.  A  careful  review  of 
literature  up  to  the  time  of  writing  shows  that  there  is 


456  BLOOD-PRESSURE 

considerable  divergence  of  opinion  on  the  value  of  such 
measures.  First,  in  any  case,  we  must  determine  the 
cause  of  high  pressure  and  the  desirability  of  reducing  it. 

Cornwall^  warns  against  too  promiscuous  employment  of 
high-frequency  treatments  in  high-pressure  cases,  par- 
ticularly in  arteriosclerosis,  in  nephritis,  and  in  the  toxic 
types.  He  bases  his  position  in  the  matter  upon  the 
ground  that  any  agent  may  do  harm  which  lowers  blood- 
pressure  without  removing  the  factor  or  factors  that 
cause  it. 

Here,  as  in  the  study  of  other  remedial  agents,  a  sys- 
tematic employment  of  the  blood-pressure  test  is  essential 
to  the  proper  interpretation  of  the  results,  as  it  is  only  by 
this  means  that  the  psychic  element  can  be  eliminated, 
which,  some  authorities  aver,  is  the  only  benefit  derived  from 
the  use  of  electrical  currents  in  the  treatment  of  hyper- 
tension. 

William  Benham  Snow^  is  conservative  in  his  statements 
regarding  the  value  of  such  measures,  and  confines  himself 
chiefly  to  the  consideration  of  the  control  of  early  cases  of 
hypertension  by  autocondensation  and  other  electrical 
measures. 

He  divides  all  cases  presenting  the  symptoms  of  hyper- 
tension into  the  following  seven  clinical  groups: 

1.  The  aged  and  feeble,  partly  compensated  arterio- 
sclerotics with  low-pressure  readings.  (These  are  not 
benefited  by  electrical  treatment — author.) 

2.  General  arteriosclerosis,  so  widespread  that  auto- 
condensation fails  to  affect  the  reading,  sequelae  cannot  be 
avoided  and  electrical  treatment  is  useless. 

» Edward  E.  Cornwall,  Jour.  Med.  Res.,  Nov.  16,  1912. 
*  Jour.  Adv.  Therap.,  June,  1909. 


ABNORMAL   BLOOD-PRESSURE  457 

3.  Arteriosclerosis  of  advanced  age,  fifty  to  sixty  years, 
pressure  above  200  mm.;  autocondensation  and  hygienic 
measures  may  cause  a  reduction  to  165  or  160  mm.,  where 
it  may  be  maintained  by  diet  and  occasional  electrical 
treatment.  There  is  a  corresponding  improvement  in 
general  health.  Electric  treatment  is  valuable  in  this  class 
if  it  can  be  continued  indefinitely  at  stated  intervals  in 
order  to  maintain  the  reduction. 

4.  Arteriosclerosis  in  adults  of  thirty-five  to  fifty-five, 
pressure  150  to  170  mm.,  with  or  without  beginning  chronic 
nephritis.  Here  fifteen-minute  treatments,  400  milliam- 
peres  by  autocondensation,  produce  marked  fall;  with 
frequent  treatments  and  correction  in  diet  the  tension 
often  returns  to  normal,  the  physical  condition  appears 
normal  and  urine  clears  up.  (These  cases  are  probably 
those  of  true  hypertension  of  Brunton,  where  there  is  no 
permanent  arterial  change  or  chronic  intestinal  nephritis — 
author.) 

5.  Same  as  class  four,  except  an  earUer  stage  of  hyper- 
tension— (author). 

6.  Young  adults,  chiefly  athletes,  who  have  developed  a 
work  hypertrophy  and  consequent  moderate  degree  of 
hypertension.  (Snow  fails  to  state  effect  of  treatment — 
author.) 

7.  Compensatory  hypertension  occurring  in  parenchy- 
matous nephritis,  cirrhosis  of  liver,  fever,  after  excessive 
exercise,  etc.  (Condition  about  the  same  as  4,  no  uni- 
formity in  results  of  treatment — author.) 

Snow  states  that  D'Arsonval  high-frequency  and  static- 
wave  currents  act  locally  upon  the  neuromuscular  mechan- 
ism.    The  method  of  D'Arsonval  may  be  either  autocon- 


458  BLOOD-PRESSURE 

densation  or  autoconduction,  by  both  of  which  methods  the 
patient  is  placed  in  a  field  of  hypotensive  stresses  where 
the  high  frequency  to  a  greater  or  lesser  extent  surges 
through  the  tissues  of  the  body,  and  is  remarkably  active 
in  lowering  arterial  tension.  ''This  effect  is  probably 
induced  by  a  complex  action  of  the  current."  Acting 
conjointly: 

1.  Upon  metabolism,  promoting  tissue  combustion  and 
elimination,  as  demonstrated  by  an  increase  in  solids  in 
the  urine,  and 

2.  Upon  the  vasodilator  centers  which  control  peri- 
pheral resistance  by  which  hypertension  is  relaxed,  as 
demonstrated  by  the  sphygmomanometer. 

A  twelve-minute  administration  of  400  milliamperes  is, 
as  a  rule,  followed  by  a  reduction  of  from  10  to  15  mm.; 
occasionally  a  fall  amounting  to  50  occurs. 

"Autocondensation  is  indicated  in  all  cases  in  which 
hypertension  is  not  compensatory  and  is  contra-indicated 
in  all  compensatory  cases"  (Snow). 

Dosage  300  to  400  milliamperes  from  twelve  to  fifteen 
minutes'  duration,  repeated  daily  or  on  alternate  days. 

Van  Allen  ^  claims  that  high-frequency  currents  reduce 
the  blood-pressure  by  removing  the  exciting  causes,  that 
is,  by  preventing  auto-intoxication 

Hirsh^  is  a  warm  advocate  of  the  electric  treatment 
of  high  blood-pressure  and  believes  that  in  certain  cases 
the  blood-pressure  even  when  very  high  is  apparently 
the  sole  factor  and  that  these  cases  are  relieved  of  their 
symptoms  only  by  a  reduction   of  their  high  pressure. 

^  Albany  Med.  Ann.,  June,  1911. 

2  A.  B.  Hirsh,  Penna.  Med.  Jour.,  December,  1914,  xviii,  3,  p.  189. 


ABNORMAL   BLOOD-PRESSURE  459 

He  cites  a  number  of  cases  where  the  D'Arsonval  treatment 
was  the  only  measure  employed,  and  relates  the  following 
characteristic  results :  The  reduction  of  the  systolic  pressure 
from  220  to  135  mm.  with  the  relief  of  symptoms  said  to 
be  of  more  than  thirty  years'  duration.  A  case  of  chronic 
parenchymatous  nephritis  with  systolic  pressure  of  240 
(an  almost  unprecedented  pressure  in  this  type  of  nephritis) 
was  reduced  to  160.  A  case  of  early  arteriosclerosis  with  a 
pressure  of  180  reduced  to  130.  A  case  of  a  woman 
sixty-one,  diagnosis  not  made,  the  systolic  pressure  of  190 
reduced  to  120,  with  ''complete  cure."  A  case  of  arterio- 
sclerosis with  cardiac  hypertrophy  and  a  pressure  of  185, 
reduced  in  two  weeks  to  155  and  kept  there  by  an  occasional 
treatment.  A  case  of  very  marked  sclerotic  and  tortuous 
vessels,  reduced  from  210  to  150.  In  the  face  of  adverse 
criticism,  this  is  an  almost  startling  array  of  evidence, 
upon  which  the  author  makes  no  comment,  it  still  being 
his  belief  that,  owing  to  the  present  status  of  electrical 
treatment,  when  a  definite  diagnosis  based  upon  a  well- 
established  pathology  can  be  made,  it  would  be  safer  to 
employ  the  usually  accepted  methods  and  reserve  the 
electrical  measures  for  those  cases  which  are  apparently 
unaffected  by  the  usual  methods. 

It  must  be  remembered  that  all  efforts  at  reduction  of 
high  blood-pressure  should  be  based  upon  a  carefully  made 
diagnosis,  and  that  the  indications  for  interfering  with  the 
circulation  must  be  clear;  otherwise  failure  may  be  ex- 
pected, for  in  some  cases  disaster  will  follow  ill-advised 
efforts  to  modify  blood-pressure.  A  safe  rule  is  to  watch 
the  patient,  study  the  effect  of  pressure  changes  upon 
him  and  cease  all  measures  that  fail  to  produce  benefit, 


460 


BLOOD-PRESSURE 


either  in  the  evident  physical  condition  of  the  patient  or 
in  the  subjective  signs. 


VENESECTION 

Miller,^  after  carefully  studying  the  effect  of  vene- 
section on  both  normal  and  pathologic  cases,  arrived  at  a 
conclusion  similar  to  that  stated  by  Mackenzie  some  years 
before.  Miller  found  that  the  rapid  withdrawal  of  300  c.c. 
or  more  from  a  normal  individual  is  followed  by  a  transi- 
tory fall  in  blood-pressure,  but  that  all  persons  do  not 
react  in  the  same  way,  the  effect  depending  partly  on  the 
degree  of  rapidity  with  which  the  blood  is  withdrawn, 
as  500  c.c.  withdrawn  slowly  may  have  no  effect  on  blood- 
pressure. 

Effect  of  Bleeding  on  Blood-Pressure  (Miller) 


Case 

Blood-pres- 
sure before 
bleeding 

Amount  of  blood 

withdrawn, 

c.c. 

Blood-pres- 
sure after 
bleeding 

1 

200 

500 

200 

2 

190 

500 

185 

3 

160 

600 

150 

Two  hours  later  160 

4 

185 

500 

170 

Two  hours  later  180 

5 

220 

450 

210 

Butterman^  bled  ten  students,  withdrawing  from  200 
to  480  c.c.  and  nine  showed  reduction  varying  from  5  to 
30  mm.  Patients  with  hypertension  do  not  necessarily 
all  react  in  the  same  way. 

The  accompanying  table  taken  from  Miller's  article 
mentioned  above  shows  what  may  be  expected  in  efforts 
to  reduce  hypertension  by  this  means. 

1  Jour.  A.  M.  A.,  Vol.  liv,  21. 

*  Arch.  f.  klin.  Med.,  1902,  Ixxiv,  1. 


INDEX 


Abdominal  pain,  355 

Absolute  pressure,  38 

Acetylsalicylic  acid,  430 

Aconite,  410 

Addison's  disease,  216 

Adrenalin,  149,  154,  422 
administration  of,  423 
in  cholera,  200 
in  chronic  nephritis,  287 
salt  solution  in  shock,  424 
spinal  injections  of,  423 

Adrenalin-novocain,  359 

Adrenals,  28 

irradiation  of,  hypertension  from, 
246 

Adults,  diastolic  pressure  in,  116 

Age,  42,  113 

in   relation   to   blood-pressure   in 
athletics,  168 

Air-pressure,  source  of,  in  sphygmo- 
manometer, 65 

Albuminuria,  after  prolonged  exer- 
cise, 179 
chronic,  404 
of  pregnancy,  387 
orthostatic,  in  children,  183 

Alcohol,  411 

effect  of,   on  venous  blood-pres- 
sure, 155 

Alcoholism,  acute,  217 
hypertension  in,  217 

Altitude,  130,  156 

effect  of,  on  pulse-rate,  157 
effect  of,  on  systolic  pressure,  207 

American  Indian,  blood-pressure  ob- 
servations in,  162 

Amino-acid  poisoning,  arteriosclero- 
sis from,  260 

Amyl  nitrite,  412 


Anaphylactic   shock   in   diphtheriSf 

198 
Anemia,  increased  pulse  pressure  in, 

138 
Aneroid  sphygmomanometer,  78 
Anesthesia,  blood-pressure  test  dur- 
ing, 354 
Anesthetics,  363 
Aneurysm,  thoracic,  228 
Aortic  insufficiency,  335 
prognosis  in,  336 
special  methods  of  determining, 
336 
regurgitation,    determining    dias- 
tolic pressure  in,  61 
Apprehension,  effect  of,  355 
Arrhythmia  after  exercise,  180 
Arsenic,  411 

poisoning,  224 
Arterial  hypotension,  determination 
of,  154 
involvement  in  chronic  nephritis, 

307 
pressure,  causes  of,  43 

contractility  of  vessel  walls  in, 

45 
definition  of,  37 
definitions  employed  in  study 

of,  36 
diastolic,  39 

effect  of  posture  on,  124,  328 
elasticity  of  vessel  walls  in,  45 
end,  38 

factors     involved     in     mainte- 
nance of,  43 
heart  energy  in,  44 
in  arteriosclerosis,  53 
lateral,  38 
minimal,  39 


461 


462 


INDEX 


Arterial  pressure,  nomenclature  of, 
37 

peripheral  resistance  in,  44 

pulse  in,  49 

terms  employed  in  study  of,  36 

total  volume  of  blood  in,  47 

viscosity  of  blood  in,  47 
system,  ramifications  of,  25 
walls,  maintenance  of  tonus  in,  30 

resistance    of,   in  sphygmoma- 
nometry,  53 
Arteries,  dilatation  of,  active,  33 

passive,  33 
elasticity  of  walls  of,  25 
examination  of,  in  arteriosclerosis, 

276 
laminal  elasticity  of,  46 
Arteriosclerosis,  254 
age  incidence  of,  260 
arterial  changes  in,  268 

pressure  in,  53 
artificial  production  of,  259 
atheroma  and,  268 
blood-pressure  in,  227,  256 

changes  in,  277 
causes  of,  261 
chronic  nephritis  and,  283 
clinical  manifestations  of,  269 
diagnosis  of,  275 
digestive  tract  in,  280 
electrotherapy  for,  457 
etiology  of,  261 
evolution,  270 

examination  of  arteries  in,  276 
excretion  of  indol  in,  290 
from  amino-acid  poisoning,  260 
from  intoxication,  257 
heart  in,  280 
Hertzell's  reaction    of    congestion 

in,  281 
high  blood-pressure  in,  294 
hot  baths  for,  449 
hypertension  in,  254,  296 
in  comparative  youth,  261 
incidence  of,  260 
increased  pulse  pressure  in,  138 


Arteriosclerosis,  kidney  involvement 
with,  266 
ocular  changes  in,  280 
pathology  of,  267 
pharmacodynamic  studies  of  cause 

of,  255 
red-hot  eye  in,  281 
relation  of,  to  tuberculosis,  206 
renal,  blood  viscosity  in,  48 
summary  of,  266 
symptomatology  of,  271 
temperature  in,  280 
toxic  theory  of,  259 
Asthma,  cardiac,  346 

in  chronic  nephritis,  303 
Atheroma,  arteriosclerosis  and,  268 
myocardial  insufficiency  from,  319 
Athletes,  diseases  causing  death  of, 

182 
Athletic  heart,  171 

disadvantages  of,  181 
Athletics,  164 

age  in  relation  to,  168 
Atmospheric  pressure,  130 
Atropin,  417 

Auricular  fibrillation,  345 
Auscultatory  method  of  sphygmoma- 
nometry,  90 
accuracy  of,  135 
additional  data,  101 
analysis  of  tone  phases  in,  95 
cardiac  strength  in,  98 
cardiac  weakness  ratio  in,  98 
classification    of    phases    of, 

92 
five  phases  of,  91,  92 
significance    of    points    and 

phases,  93 
significance  of  tone  phases  in, 

96 
versus  other  methods,  99 
sounds  in  prognosis  of  pneumonia, 
192 
Autocondensation,  458 
Aviation  sickness,  217 
hypotension  in,  217 


INDEX 


463 


Baslek's  ochrometer,  143 
Baths,  cold,  448 
electric-Hght,  450 
hot,  449 
hot-air,  450 
oxygen,  454 
parogen,  455 
Beer,  effect  of,  132 
BiUary  coHc,  228 

Blood  composition,   relation  of,   to 
surgical  operations,  373 
total  volume  of,  in  arterial  pres- 
sure, 47 
transfusion,  372 

viscosity  of,  in  arterial  pressure, 
47 

in  renal  arteriosclerosis,  48 
Blood-pressure,  36 
abnormal,  21 

physical  measures  for,  436 
absolute,  38,  156 

after  exercise  at  fifty-five  years  and 
over,  175 
m  early  life  to  young  man- 
hood, 169 
in  manhood  to  forty  years, 

173 
in  middle  age,  173 
average,  41 

value  of  determination  of,  43 
capillary,  142 

conditions  influencing,  142 
effect  of  cold  on,  145 
importance  of,  143 
instruments     for     determining, 

143 
methods  of  measuring,  143 
normal,  144 

modifications  of,  144 
changes  in  arteriosclerosis,  277 
chart,  86,  87 

clinical  determination  of,  89 
conditions  affecting,  57 
definition  of,  37 

determination  of.  See  Sphygmoma- 
nometry. 


Blood-pressure,    determination    of, 

after  exercise,  182 
diastolic  in  aortic  regurgitation,  61 

in  chronic  nephritis,  299 

in  typhoid  fever,  195 

tactile  determination  of,  61 
diurnal  variations  in,  126 
drugs  affecting,  therapeutic  value 

of,  409 
effect    of    abdominal     pain     on, 
355 

of  acetylsalicylic  acid  on,  430 

of  aconite  on,  410 

of  adrenalin  on,  422 

in  chronic  nephritis,  287 

of  adrenalin-novocain  on,  359 

of  adrenals  on,  28 

of  age  on,  42,  113 

of  alcohol  on,  155,  411 

of  altitude  on,  130,  156 

of  amyl  nitrite  on,  412 

of  apprehension  on,  355 

of  anesthetics  on,  363 

of  arsenic  on,  411 

of  athletics  on,  164 

of  atropin  on,  417 

of  beer  on,  132 

of  body-strength  on,  120 

of  caffein  on,  417 

of  calomel  on,  419 

of  camphor  on,  419 

of  cardiac  hypertrophy  on,  167 

of  changes  in  intra-abdominal 
pressure  on,  132 

of     changes     in     intrathoracic 
pressures  on,  132 

of  chloral  on,  419 

of  chloroform  on,  366,  419 

of  digestion  on,  131 
in  labor,  396 

of  choliti  salts  on,  259 

of  climate  on,  156,  160 

of  cocain  on,  419 

of  diet  regulation  on,  413 

of  digitalis  on,  419,  420 

of  drink  on,  131 


464 


INDEX 


Blood-pressure,  effect  of  drugs  on,  in 

labor,  395 
of  emotion  on,  121 
of  epinephrin  on,  422 
of  ergot  on,  424 

in  labor,  395 
of  erythrol  tetranitrate  on,  414 
of  ether  on,  365 
of  ethyl  chlorid  on,  424 
of  ethyl  chlorid  on,  371 
of  excitement  on,  121 
of  exercise  on,  128,  164,  440 
of  fear  on,  58,  355 
of  food  on,  131,  442 
of  glandular  secretions  on,  28 
of  guipsine  on,  425 
of  hemorrhage  on,  361 
of  hormonal  on,  425 
of  induced   pneumothorax  on, 

357 
of  iodin  on,  425 
of  kidney  extracts  on,  27 
of  labor  on,  387 
of  lumbar  puncture  on,  358 
of  mannitol  hexanitrate  on,  414 
of  massage  on,  130,  441 
of  menstruation  on,  132 
of  morphin  on,  427 
of    muscular    development    on, 

120 
of  Nauheim  treatment  on,  451 
of  nitrite  group  on,  412 
of  nitroglycerin  on,  413 
of  nitrous  oxid  on,  369 
of  nitrous  oxid-ether  on,  369 
of  nitrous  oxid-oxygen  on,  370 
of  operative  procedures  on,  355 
of  oxygen  baths  on,  355,  454 
of  pain  on,  355 
of  paracentesis  on,  356 
of  passive  movements  on,  130 
of  peritoneal  incision  on,  355 
of  physical  exercise  on,  128 

fitness  on,  164 
of  physostigmin  on,  460 
of  pilocarpin  on,  427 


Blood-pressure,    effect  of  pituitary 
gland  on,  28,  428 
in  labor,  395 
of  posture  on,  123,  134 
of  psychic  disturbances  on,  58 
of  purging  drugs  on,  428 
of  race  on,  156,  161 
of  regulated  diet  on,  439 
of  rest  on,  125 
of  salicylates  on,  430 
of  salvarsan  on,  372 
of  scopolamin-morphin  narcosis 

on,  396 
of  sex  on,  119 
of  shock  on,  379 
of  size  on,  120 
of  skin  incision  on,  355 
of  sleep  on,  125,  439 
of  sodium  nitrate  on,  413 
of  somnoform  on,  371 
of  spinal  puncture  on,  366 
of  strychnin  on,  431 
of  surgical  procedures  on,  355 
of  thiosinamin  on,  431 
of  thyroid  on,  28,  432 
of  tobacco  on,  432,  443 
of  urethan  on,  434 
of  valvular  defects  on,  167 
of  vasotonin  on,  434 
of  venesection  on,  460 
of  veratrum  viride  on,  434 
of  vomiting  on,  134 
of  walking  on,  128 
of  x-ray  on,  29 
of  yohimbin  on,  434 

errors  in  tactile  method  of  deter- 
mining, 60 

extreme  low,  242 

failure  of  circulation  and,  20 

findings  in  prognosis  of  tubercu- 
losis, 207 

high,  243.     See  also  Hypertension. 

imparting   knowledge   of,   to   pa- 
tient, 60 

in    accidental    complications    of 
tuberculosis,  209 


INDEX 


465 


Blood-pressure  in  acute  alcoholism, 
217 
infections,  187 
nephritis  in  children,  185 
of  scarlet  fever,  199 

in  Addison's  disease,  216 

in  albuminuria  of  pregnancy,  389 

in    anaphylactic    shock    in    diph- 
theria, 198 

in  arsenic  poisoning,  224 

in  arteriosclerosis,  227,  256 

in  athletics,  age  in  relation  to,  168 

in  auricular  fibrillation,  345 

in  aviation  sickness,  217 

in  biliary  colic,  220 

in  bradycardia,  345 

in  caisson  workers,  131 

in  cardiac  asthma,  218 

in  cerebral  hemorrhage,  219 

in  Cheyne-Stokes  respiration,  222 

in  children,  183 

in  cholera,  200 

in  chronic  affections,  187 
albuminuria,  404 
myocarditis,  406 
nephritis,  307,  405 

in  compressed-air  workers,  158 

in  congenital  heart  deformity,  227 

in  deep  mines,  158 

in  diabetes  mellitus,  223 

in  eclampsia,  391 

in  epidemic  cerebrospinal  menin- 
gitis, 201 

in  epilepsy,  232 

in  epistaxis  with  increased  vascu- 
lar tension,  227 

in  glaucoma,  375 

in  glycosuria  of  pregnancy,  389 

in  gynecologic  operations,  357 

in  heart  disease,  334 

in  hemorrhage  in  pregnancy,  389 
in  tuberculosis,  209 
in  typhoid,  196 

in  Hodgkin's  disease,  229 

in  incipient  tuberculosis,  406 
in  infectious  diseases,  187 
30 


Blood-pressure    in    infectious    dis- 
eases, methods  of  study,  189 

in  intracranial  hemorrhage,  361 

in  laryngitis,  200 

in  malaria,  200 

in  mania,  233 

in  metabolic  conditions,  216 

in  Momburg  constriction,  225 

in  morphinism,  225 

in  neurasthenia,  230 

in  neurologic  conditions,  216 

in  neuroretinitis,  375 

in  optical  disorders,   surgical  as- 
pects of,  379 

in     orthostatic     albuminuria     in 
children,  183 

in  overweights,  405 

in  paresis,  233 

in  paroxysmal  tachycardia,  345 

in   perforation  in  typhoid  fever, 
195 

in   pernicious   vomiting   of   preg- 
nancy, 389 

in  phosphorus  poisoning,  224 

in  .pleural  effusions,  226 

in  pneumonia,  189 
in  children,  185 

in  polycythemia,  226 

in  pregnancy,  complications  affect- 
ing, 387 

in  pulmonary  edema,  218 

in  relation  to  mortality,  40"^ 

in  renal  colic,  228 

in  retinal  edema,  375 

in  scarlet  fever,  198 

Rolleston's  table  of,  199 

in  spinal  anesthesia,  358 
cord  operations,  357 

in  syphilis,  213 

in  tabes  dorsalis,  232 

in  thoracic  aneurysm,  228 

in  toxemia  of  pregnancy,  391 

in  tuberculosis,  159,  203 
charts  of,  212,  213 
effect  of  exercise  on,  210 
of  open  air  on,  159 


466 


INDEX 


Blood-pressure  in  typhoid  fever,  194 
complications,  195 
readings  in,  194 
in  valvular  heart  disease,  227 
instrumental  estimation  of,  50 
instruments,  classification  of,  68 
keeping  records  of,  59 
level,  normal,  in  pneumonia,  193 
low.     See  Hypotension. 

systolic,   in  early  tuberculosis, 
204 
maintenance   of,   in   hemorrhage, 
363 

in  veins,  150 
maximal,  38 
mean,  41 

negative  phase  in,  177 
normal,  109,  112 

attainment  of,  26 

formula  for,  401 

general  considerations,  609 

in  pregnancy,  385 

non-pathologic  factors  affecting, 
109 

physiologic  factors  affecting,  109 

variations  of,  109,  113 
observations  in  American  Indian, 
162 

in  Philippines,  160 
ophthalmologic  data  on,  373 
performance  of  test,  59 
periodic  variations  in,  127 
physical  measures  for  reduction  of, 

438 
quotient,  139 
readings,  abnormal,  118 
record,  59 
reduced,  in  tuberculosis,  theory  of, 

208 
relation  of,  to  crises  in  pneumonia, 
193 

to  shock,  349 

to  surgery,  347 
relative,  156 
return  to  normal  of,  after  exercise, 

177 


Blood-pressure,  rise  of,  from  hyper- 
alimentation, 209 
secondary     and    late    effects    of 

typhoid  fever,  196 
sleep  drop  of,  125 
systolic,  38 

accuracy  of  estimation,  39 
arterial,  24 
causes  of  fall  in,  44 
causes  of  rise  in,  44 
effect  of  altitude  on,  207 
in  chronic  nephritis,  299 
in  post-operative  collapse,  352 
time  of  observation  of,  57 
toxemia  and,  187 
transmitted  intraventricular,  38 
Traube-Herring  waves  in,  127 
value  of  estimation  of,  54 
vasomotor  mechanism  controlling, 

30 
venous,  142,  146 
average,  153 

clinical  importance  of,  153 
diurnal  rhythm  of,  152 
effect  of  caffein  on,  153 
of  digitalis  group  on,  154 
of  drugs  on,  154 
of  epinephrin  on,  149,  154 
of  exercisfe  on,  151 
of  external  compression  on, 

152 
of  intravenous  injection  on, 

152 
of  morphin  on,  155 
of    myocardial    degeneration 

on,  152 
of  nitrites  on,  155 
of  pituitrin  on,  155 
of  position  of  part  on,  151 
of  posture  on,  151 
of  strychnin  sulphate  on,  155 
factors  influencing,  151 
Gartner's  method  of  measuring, 

147 
general  considerations,  146 
high,  in  pleural  effusions,  150 


INDEX 


467 


Blood-pressure,     venous,     Howell's 
method  of  measuring,  147 
methods  of  measuring,  146 
normal,  152 
physics  of,  149 
physiology  of,  149 
relation   of   pulse   pressure   to, 

152 
respiratory  variation  in,  152 
Vierordt's  method  of  measuring, 
63 
Boat-racing,  effect  of,  on  heart,  179 
Body  strength,  effect  of,  120 
Boys,  effect  of  excessive  exercise  on 
heart  in,  182 
regulation  of  exercise  for,  170 
Bradycardia,  345 
Brain  operations,  357 
Bright's     disease,     282.     See     also 
Nephritis,  chronic. 


Cachexia,  decreased  pulse  pressure 

in,  139 
Caffein,  417 

effect  of,  on  venous  pressure,  155 
Caisson  workers,  131 
Calomel,  419 
Camphor,  419 
Capillaries,  functions  of,  25 
Capillary  pressure,  142 

conditions  influencing,  142 
effect  of  cold  on,  145 
importance  of,  143 
instruments    for     determining, 

143 
methods  of  measuring,  143 
normal,  144 

modifications  of,  144 
Carbon  dioxid,  effect  of,  on  circula- 
tion, 27 
Cardiac  asthma,  346 

blood-pressure  in,  218 
in  chronic  nephritis,  303 
compensation,  preservation  of,  in 
chronic  nephritis,  315 


Cardiac     dilatation,      acute,     from 
violent  exercise,  180 
diseases,  317,  334 
chronic  valvular,  333 
effect  of,  on  circulation,  20 
functional,  333 
efficiency  in  chronic  nephritis,  305 
in  relation  to  exercise,  165 
potential  reserve  in,  166 
relation  of  physical  fitness  to, 
170 
evidence  in  chronic  nephritis,  304 
hypertrophy,  effect  of,  on  blood- 
pressure,  167 
insufficiency,  development  of,  166 
load,  340 

neuroses,  pulse  pressure  in,  344 
overload,  340 

overstrain,  permenant  result  of,  180 
size  and    efficiency,  exercise    and 
study  of,  172 
Cardiovalvular    defects,    regulation 
of  exercise  in,  170 
system,  effect  of  exercise  on,  165 
Cardiovascular-renal  diseases,  causes 

of  failure  in  treatment  of,  436 
Carotid  artery,  elasticity  of,  47 
Cerebral  hemorrhage,  219 
Cerebrospinal  meningitis,  epidemic, 

201 
Chambers'    observations   in   Philip- 
pines, 160 
Cheyne-Stokes  respiration,  222 
Children,  blood-pressure  in,  183 
in  acute  nephritis,  185 
orthostatic  albuminuria  in,  183 
pneumonia  in,  185 
use  of  sphygmomanometer  on,  185 
Childhood,  systolic  pressure  in,  115 
Chloral,  419 

Chloroform,  366,  396,  419 
Cholera,  200 

adrenalin  in,  200 
hypotension  in,  200 
Cholin  salts,  influence  of,  on  blood- 
pressure,  259 


468 


INDEX 


Circulation,  14,  21 

chemical  changes  in,  26 
course  of,  22 
diagram  of,  22 
effect  of  arterial  walls  on,  23 
of  carbon  dioxid  on,  27 
of  exercise  on,  176 
of  heart  disease  on,  20 
of  lactic  acid  on,  27 
factors  controlling,  22 

maintaining  equilibrium  of,  34 
failure  of,  20 

general  considerations,  20 
mechanical  arrangements  of,  23 
normal,  21 

importance  of,  20 
principles  controlling,  23 
Circulatory  system,  effect  of  hydro- 
statics on,  24 
Climate,  influence  of,  156,  160 
Cocain,  419 

Cold,   effect  of,   on  capillary  pres- 
sure, 145 
Coma,  blood-pressure  test  in  diag- 
nosis of,  222 
Compressed-air      workers,      blood- 
pressure  in,  158 
Compression,  external,  effect  of,  on 
venous  pressure,  152 
member   of   sphygmomanometer, 
65 
relation  to  artery,  66 
Cook's  modification  of  Riva-Rocci 
sphygmomanometer,  70 
disadvantages,  70 
Corneal  ulcer,  379 
Cuff  of  sphygmomanometer,  char- 
acter of,  51 
standard  width  for.  111 

D'Arsonval     high-frequency     cur- 
rents, 457 

Diabetes  mellitus,  223 

Diabetic  coma,  blood-pressure  test 
in,  diagnosis  of,  224 
complications,  hypertension  in,  224 


Diastolic  arterial  pressure,  39 
index,  141 

determination  of,  106 
indicator,  Fedde,  105 
point,  variation  of  opinion  on,  135 
pressure,  importance  of  determin- 
ing, 344 
in  adults,  116 
in  palpatory  method  of  sphyg- 

momanometry,  103 
in  typhoid  fever,  195 
in  visual  method  of  sphygmoma- 

nometry,  103 
influence  of  digitalis  on,  421 
normal  variations  in,  113 
Swan's  fourth  point  in,  135 
Diet  list,  444-446 

regulation  of,  443 
Dietetics,  441 
Digestion,  effect  of,  131 
Digestive   tract   in    arteriosclerosis, 

280 
Digitalis,  419 
administration  of,  421 
contra-indications  to  use  of,  422 
group,  effect  of,  on  venous  pres- 
sure, 154 
rules  for  use  of,  421 
Dilatation  of  arteries,  active,  33 

passive,  33 
Diphtheria,  197 

anaphylactic  shock  in,  198 
hypotension  in,  198 
Diurnal  rhythm  of  venous  pressure, 
152 
variations  in  blood-pressure,  126 
Drink,  effect  of,  131 
Dropsy  in  chronic  nephritis,  316 
Drugs      affecting       blood-pressure, 
therapeutic  value  of,  409 
effect  of,  in  labor,  395 
in  pregnancy,  395 
on  venous  pressure,  154 
in  chronic  nephritis,  315 
nitrite  group,  412 
purging,  428 


INDEX 


469 


Early    life    to    young    manhood, 
blood-pressure   after   exercise    in, 
169 
Eclampsia,  391 
Edema  in  chronic  nephritis,  303 

retinal,  375 
Electrotherapy,  455 

for   arteriosclerosis,    457 
Emotion,  effect  of,  121 
Energy  expended  by  normal  heart 
in  youth,  165 
index,  140 

determination  of,  140 
potential,  of  heart,  166 
Epilepsy,  232 

Epinephrin,  422.      See  also   Adren- 
alin. 
Epistaxis,  prolonged,  with  increased 

vascular  tension,  227 
Ergostat  for  measuring  energy  ex- 
pended, 128 
Ergot,  395,  424 

Erlanger's  sphygmomanometer,  84 
disadvantages,  86 
in  use,  85 
Erythrol  tetranitrate,  414 
Ether,  365 

Ethyl  chlorid,  371,  424 
Excitement,  effect  of,  121 
Exercise,  164,  182,  440 
arrhythmia  after,  180 
blood-pressure  after,  at  fifty-five 
years  and  over,  175 
in  early  life  to  young  man- 
hood, 169 
in  manhood  to  forty  years, 

173 
return  to  normal,  177 
cardiac  efficiency  in  relation  to, 
165 
size  and  efficiency  and,   study 
of,  172 
effect  of,  in  tuberculosis,  210 
on  cardiovascular  system,  165 
on  circulation,  176 
on  heart,  171,  176 


Exercise,  effect  of,  on  respiration,  176 
on  venous  pressure,  151 
examination  of  heart  after,  182 
excessive,  effect  on  heart  in  boys, 
182 
hypertrophy  of  heart  from,  181 
valvular  insufficiency  from,  181 
in     middle     age,     blood-pressure 

after,  173 
prolonged,  albuminuria  after,  179 
permanent  result  of,  180 
small  pulse  pressure  after,  179 
pulse  rate  in,  178 

return  to  normal,  178 
regulation  of,  for  boys,  170 

in  cardiovalvular  defects,  170 
systolic  murmur  after,  179 
violent,    acute   cardiac   dilatation 
from,  180 
Exertion,  effect  of,  128 
Eye,  red-hot,  in  arteriosclerosis,  281 
Eye-ground  examination  in  chronic 
nephritis,  309 


Faught   mercury  sphygmomanom- 
eter, 74 
advantages,  74 
pocket  sphygmomanometer,  81 
advantages,  81 
clinical,  83 

advantages,  84 
dial  of,  83 
in  use,  82 
diagram  of,  79 
with  Fedde  indicator,  105 
index   card  for   recording  blood- 
pressure,  59 
Fear,  effect  of,  58,  355 
Fedde  diastolic  indicator,  105 

Faught    sphygmomanometer 
with,  105 
Fibrillation,  auricular,  345 
Fifty-five    years    and    over,    blood- 
pressure  after  exercise  at,  175 
Foods,  131,  441 


470 


INDEX 


Gartner's  method  of  measuring 
venous  blood-pressure,  147 

Gauge  of  sphygmomanometer,  68 

Gibson's  rule  in  pneumonia,  190 

Glandular  secretions,  28 

Glaucoma,  375 

Glycosuria  of  pregnancy,  389 

Graphic  method  of  sphygmoma- 
nometry,  104 

Graupner's  test  in  myocardial  in- 
sufficiency, 331 

Guipsine,  425 

Gynecologic  operations,  357 

Hales'  manometers,  62 
Harvey's  research  work  on  circula- 
tion, 20 
Heart,  athletic,  171 

disadvantages  of,  181 
cases,  effect  of  postural  change  in, 
329 
relation    of    pulse    pressure    to 
venous  pressure  in,  330 
deformity,  congenital,  227 
diminution  in  size,  during  exercise, 

180 
effect  of  boat-racing  on,  179 

of  excessive  exercise  on,  in  boys, 

182 
of  exercise  on,  171,  176 
of  long-distance  running  on,  179 
of  muscular  work  on,  328 
energy  in  arterial  pressure,  44 
of  examination  of,  before  exercise, 

182 
failure,  camphor  in,  419 

fall  of  blood-pressure  in,  326 
from   myocardial  insufficiency, 
326 
fatty  degeneration  of,  cause  of,  321 
in  arteriosclerosis,  280 
normal,  in  youth,  energy  expended 

by,  165 
potential  energy  of,  166 
Hemorrhage,  361 
cerebral,  219 


Hemorrhage,     concealed,    diagnosis 
of,  362 

critical  factor  in,  362 

in  pregnancy,  389 

in  tuberculosis,  209 

in  typhoid  fever,  196 

retinal,  causes  of,  377 
systolic  pressure  and,  376 
Hertzell's  reaction  of  congestion  in 

arteriosclerosis,  281 
Hill's  sphygmomanometer,  64 
Hodgkin's  disease,  229 
Hormonal,  425 

Howell's  method  of  measuring  ven- 
ous pressure,  147 
Hydrostatics,   effect  on  circulatory 

system,  24 
Hydrotherapy,  447 
Hyperalimentation,  209 
Hyper piesis,  243.     See  also  Hyper- 
tension. 
Hypertension,  243 

arteriosclerosis  and,  254 

causes  of  death  in,  295 

cold  baths  for,  448 

definition  of,  243,  244 

diagnosis  of,  252 

electrotherapy  for,  450,  456 

etiology  of,  246 

from  chronic  toxemia,  249 

from  intoxication,  246 

from  irradiation  of  adrenals,  246 

from  obesity,  248 

from  syphilis,  252 

hot-air  baths  for,  450 

hot  baths  for,  449 

hydrotherapy  in,  448 

in  alcoholism,  217 

in  arteriosclerosis,  294,  296 

in  chronic  nephritis,  285,  295 
chemical  theory  of,  286 
retention  theory  of,  290 

in  diabetic  complications,  224 

influence  of  sweating  on,  450 

nephritic,   and  chronic  nephritis, 
282 


INDEX 


471 


Hypertension,  posture  for,  438 

provocative  causes  of,  248 

relation    of,    to    chronic    kidney 
changes,  293 

rest  for,  438 

Scotch  douche  for,  449 

secondary,  in  lead-poisoning,  224 

symptomatology  of,  249 

systolic  pressure  level  in,  251 

true,  244 
Hypertonia  vasorum,  245 
Hypertrophy  of  heart  from  excessive 

exercise,  181 
Hypotension,  235 

arterial,  determination  of,  154 

at  term  in  pregnancy,  391 

causes  of,  241 

danger  of,  242 

definition,  235 

effects  of,  242 

essential  constitutional,  238 

in  advanced  tuberculosis,  210 

in  aviation  sickness,  217 

in  cholera,  200 

in  diphtheria,  198 

in  neurasthenia,  231 

in  scarlet  fever,  199 

in  tuberculosis,  204,  205 

lower  normal  limits  of,  235 

relative,  239 

secondary,  240 

temporary,  240 

terminal,  236 

true,  238 

varieties  of,  236 


Index,  diastolic,  141 

determination  of,  106 
energy,  140 

determination  of,  140 
S.  D.  R.,  140 

determination  of,  140 
Indicator  of  sphygmomanometer,  68 
Indol   excretion   in   arteriosclerosis, 

290 
Inefficiency,  myocardial,  323 


Infections,  acute,  blood-pressure  in, 
187 

chronic,  blood-pressure  in,  203 
Infectious  diseases,  187 

effect  of,  on  myocardium,  180 
study  of,  189 
Insufficiency,  aortic,  355 

myocardial,  317 
Intra-abdominal  pressures,  changes 

in,  132 
Intracranial  hemorrhage,  361 
Intrathoracic  pressures,  changes  in, 

132 
Intravenous  injection,  effect  of,  on 

venous  pressure,  152 
lodin,  425 

Jane  way's  sphygmomanometer,  72 
advantages,  74 
disadvantages,  74 
Katzenstein's    test    in    myocardial 

insufficiency,  331 
Kercher  mercury   sphygmomanom- 
eter, 78 
Kidney  extracts,  27 

involvement  with  arteriosclerosis, 
266 

Labor,  387 

Lactic  acid,  effect  on  circulation,  27 

Laryngitis,  200 

Lead  poisoning,  224 

secondary  hypertension  in,  224 

Life  insurance  examinations,  397 
application  of  test  in,  403 
chronic  albuminuria  in,  404 
estimating    normal    pressure 

in,  401 
in  chronic  myocarditis,  406 

nephritis,  406 
in  incipient  tuberculosis,  406 
in  overweights,  405 
permissible  variations,  401 
relation  of  pressures  in,  403 

Load,  cardiac,  340 

Lumbar  puncture,  358 

Lungs,  edema  of,  in  chronic  nephri- 
tis, 303 


472 


INDEX 


Malaria,  200 

Manhood  to  forty  years,  blood-pres- 
sure after  exercise  in,  173 

Mania,  233 

Mannitol  hexanitrate,  414 

Manometer  of  sphygmomanometer, 
68 

Manometers,  Hales',  62 

Marey's  sphygmomanometer,  63 

Massage,  130,  441 

Maximal  pressure,  38 

Melancholia,  233 

Menstruation,  132 

Mental  excitement,  355 

Mercury     sphygmomanometer, 
Faught,  74 
advantages,  75 
folding,  76 

Middle    age,    blood-pressure    after 
exercise  in,  173 

Midget  folding  mercury  sphygmo- 
manometer, 76 

Mines,  deep,  158 

Minimal  arterial  pressure,  39 

Mistletoe,  active  principle  of,  425 

Mitral  defects,  339 
stenosis,  339 

Momburg  constriction,  225 
pulse  pressure  in,  225 

Morphin,  427 
effect  of,  on  venous  pressure,  155 

Morphinism,  225 

Mortality,  relation  of,  to  blood-pres- 
sure, 407 

Muscular  development,  120 
insufficiency,    Shapiro's    test    in, 

331 
work,  effect  of,  on  heart,  328 

Myocardial  degeneration,  effect  of, 
on  venous  pressure,  152 
efficiency,  determination  of,  341 

diagnosis  of,  327 
inefficiency,  323 
insufficiency,  317 

cautions  to  observe  in  tests  for, 
333 


Myocardial  insufficiency,   definition 
of,  323 
effect  of  strain  on,  325 
etiology  of,  319 
from  atheroma,  319 
from  fatty  degeneration,  319 
from  strenuous  life,  319 
Graupner's  test  in,  331 
heart  failure  from,  326 
in     chronic     valvular     disease, 

333 
in    functional    cardiac    disease, 

333 
pulse  pressure  in,  138 
secondary  factors  contributing 

to,  324 
significance  of  term,  317 
symptomatology  of,  326 
varieties  of,  324 
sufficiency,  323 
Myocarditis,  chronic,  406 
Myocardium,    effect    of    infectious 
diseases  on,  180 

Nauheim  treatment,  451 
application  of,  452 
general  effects  of,  452,  453 
special  exercise  in,  454 
Negative   phase   in   blood-pressure, 

177 
Nephritic  hypertension  and  chronic 

nephritis,  282 
Nephritis,  acute,  199 
in  children,  185 
chronic,  282,  307,  405 

arterial  involvement  in,  307 
arteriosclerosis  and,  283 
cardiac  asthma  in,  303 
efiiciency  in,  305 
evidence  in,  304 
causes  of  death  in,  312, 
diagnosis  of,  304 
dropsy  in,  316 
drug  treatment  of,  315 
edema  in,  303 
etiology,  282 


INDEX 


473 


Nephritis,  chronic,  excretion  of  urea 
in,  290 
eye-ground  examination  in,  309 
general   physical   condition   in, 

305 
hypertension  in,  285 
increased  pulse  pressure  in,  138 
ocular  signs  in,  304 
pathology  of,  292 
phthalein  test  in,  308 
preservation  of  cardiac  compen- 
sation in,  315 
prognosis  in,  310 
renal   functional    efficiency    in, 

307 
salt  restriction  in,  316 
signs  of,  295 

subjective  symptoms  in,  304 
summary  of,  313 
symptoms  of,  295 
treatment,  314 
urinary  findings  in,  301,  303 
mixed,  283 
Neurasthenia,  230 

hypotension  in,  231 
Neuroretinitis,  375 
Nicholson   folding   mercury   sphyg- 
momanometer, 76 
Nitrite  group  of  drugs,  412 
Nitrites,  effect  of,  on  venous  pres- 
sure, 155 
Nitroglycerin,  413 
Nitrous  oxid,  369 
oxid-ether,  369 
oxid-oxygen,  370 

Obesity,  hypertension  from,  248 

Obstetrics,   blood-pressure  observa- 
tion in,  384 

Ochrometer,  Basler's,  143 

Ocular   changes   in    arteriosclerosis, 
280 
signs  in  chronic  nephritis,  304 

Open  air,  effect  of,  in  tuberculosis, 
159 

Operative  procedures,  effect  of,  355 


Ophthalmologic  data  on  blood-pres- 
sure, 373 

Ortel  treatment,  454 

Oscillatory  method  of  sphygmo- 
manometry,  104 

Overload,  cardiac,  340 

Overweights,  405 

Oxygen  baths,  454 

Pain,  355 

Palpatory  method  of  sphygmoma- 
nometry,  102 
diastolic  pressure  in,  103 
systolic  pressure  in,  102 

Paracentesis,  356 

Paresis,  233 

Passive  movements,  130 

Patient,  imparting  information  to, 
60 

Perforation,  typhoid,  195 

Periodic  variations  in  blood-pres- 
sure, 127 

Peripheral  resistance  in  arterial 
pressure,  45 

Peritoneal  incision,  effect  of,  355 

Pernicious  vomiting  of  pregnancy, 
389 

Perogen  bath,  455 

Philippines,  blood-pressure  observa- 
tions in,  160 

Phosphorus  poisoning,  224 

Phthalein  test  in  chronic  nephritis, 
308 

Physical  exercise,  128 
fitness,  164 

relation  of  cardiac  efficiency  to, 
170 
measures   for    reducing    pressure, 
438 

Physics  of  venous  pressure,  149 

Physiology,  14 

of  venous  pressure,  149 

Physostigmin,  410 

Pilling-White  graphic  sphygmoma- 
nometer, 87,  88 

Pilocarpin,  427 


474 


INDEX 


Pituitary  extract,  28,  395,  428 

effect  of,   on  venous  pressure, 
155 
Pleural  effusions,  226 

high  venous  pressure  in,  150 
Pneumonia,  189 

auscultatory  sounds  in  prognosis 

of,  192 
Gibson's  rule  in,  190 
in  children,  185 

normal  blood-pressure  level  in,  193 
Pneumonia,  crisis  in,  193 
Pneumothorax,  induced,  357 
Polycythemia,  226 
Posture,  123,  134 

effect  of,  in  hypertension,  438 
on  arterial  pressure,  124 
on  pulse  pressure,  124 
on  venous  pressure,  151 
Potain's  sphygmomanometer,  63 
Pregnancy,  albuminuria  of,  387 
blood-pressure  test  in,  frequency 

of,  385 
drugs  in,  395 
glycosuria  of,  389 
hemorrhage  in,  389 
normal  blood-pressure  in,  385 
pernicious  vomiting  of,  389 
toxemia  of,  391 

value  of  blood-pressure  test  in,  384 
Psychic  disturbances,  influences  of 

fear  on,  58 
Pulmonary  edema,  218 
Pulse,  amplitude,  40 
in  arterial  pressure,  49 
pressure,  40,  135 

changes,  significance  of,  138 
decreased,  cachexia  in,  139 

significance  of,  139 
determination  of,  136 
effect  of  posture  on,  124 
in  arrested  hemorrhage,  363 
in  cardiac  neuroses,  344 
in  Momburg  constriction,  225 
in  myocardial  insufficiency,  138 
in  tuberculosis,  208 


Pulse  pressure,  increased,  in  anemia, 
138 
in  arteriosclerosis,  138 
in  chronic  nephritis,  138 
large,  138 
low,  137 

normal  variations  in,  113 
relation    of,    to  other  pressure 
values,  137 
of  venous  pressure  to,  152 
in  heart  cases,  330 
small,  after  prolonged  exercise, 

179 
urinary  excretion  and,  301 
range,  40 
rate  after  exercise,  178 

return  to  normal,  178 
'effect  of  altitude  on,  157 
Purging  drugs,  428 

Quotient,  blood-pressure,  139 

Race,  influence  of,  on  blood-pres- 
sure, 156,  161 
Reflexes,  vasomotor,  33 
Renal  colic,  228 

functional    efficiency    in    chronic 

nephritis,  307 
Respiration,  Cheyne-Stokes,  222 

effect  of  exercise  on,  176 
Respiratory    variation     in     venous 

pressure,  152 
Rest,  125,  439 

in  hypertension,  438 
Retinal  edema,  375 

hemorrhage,  causes  of,  377 
systolic  pressure  and,  376 
Riva-Rocci  sphygmomanometer,  64, 
69,  70 
advantages,  70 
disadvantages,  70 
RoUeston's  table  of  blood-pressure 

in  scarlet  fever,  199 
Running,    long-distance,    effect    on 

heart,  179 


INDEX 


475 


Salicylates,  430 

Salt  restriction  in  chronic  nephritis, 
316 

Salvarsan,  administration  of,  372 
Sands  sphygmomanometer,  71 

disadvantages,  72 
Scarlet  fever,  198 

hypotension  in,  199 
Rolleston's  table  in,  199 
Schott  treatment,  454 
Scopolamin-morphin  narcosis,  396 
Scottish  douche,  449 
S.  D.  R.  index,  140 
Sex,  effect  of,  on  blood-pressure,  119 
Shapiro's  test  in   muscular  insuffi- 
ciency, 331 
Shock,  349,  379 

adrenalin  salt  solution  in,  424 
theories  of  origin  of,  380 
varieties  of,  381 
Size,  effect  of,  on  blood-pressure,  120 
Skin  incision,   effect  of,   on  blood- 
pressure,  355 
Sleep,  125,  439 

drop  in  blood-pressure,  125 
Sodium  nitrite,  413 
Somnoform,  371 

Sphygmomanometer,  aneroid,  78 
application  of  cuff  of,  57 
character  of  cuff  in,  51 
compression  member  of,  65 

relation  to  artery,  66 
development  of,  63 
Erlanger's,  84 

disadvantages,  86 
in  use,  85 
Faught  mercury,  74 
advantages,  74 
pocket,  81 

advantages,  81 
clinical,  83 

advantages,  84 
diagram  of,  79 
dial  of,  83 
in  use,  82 
folding  mercury,  76 


Sphygmomanometer,    folding    mer- 
cury, Midget,  76 

Nicholson,  76 
gauge  of,  68 
Hill's,  64 

importance  of  condition  of  indi- 
cator and  cuff  of,  58 
in  children,  186 
indicator  of,  68 
Janeway's,  72 

advantages,  74 

disadvantages,  74 
manometer  of,  68 
Marey's,  63 
mercury,  Kercher,  78 
method  of  employing,  56,  62 
parts  of,  65 

Pilling- White  graphic,  87,  88 
pocket,  diagram  of,  80 
Potain's,  63 

precautions  in  using,  56 
principle  of,  50 
Riva-Rocci,  64,  69,  70 

advantages,  70 

Cook's  modification,  70 
disadvantages,  70 
Sands,  71 

disadvantages,  72 
source  of  air-pressure  in,  65 
standard  cuff  width  for.  111 
Stanton's,  71 

disadvantages,  72 
suggestions   for  using,  56 
technique  of  employment,  65 
varieties  of,  62 
von  Basch's,  63 
Sphygmomanometers,    classification 

of,  68 
faults  of  older  instruments,  55 
modern,  description  of,  69 
Sphygmomanometry,  application  of, 

in  surgical  cases,  353 
auscultatory  method,  90 
accuracy  of,  135 
additional  data,  101 
analysis  of  tone  phases  in,  95 


476 


INDEX 


Sphygmomanometry,       ausculatory 
method,  cardiac  strength 
in,  98 
weakness  ratio  in,  98 
classification  of  phases  of,  92 
five  phases  of,  91,  92 
significance    of    points    and 
phases,  93 
of  tone  phases  in,  96 
variations  in  tone  phases  of, 
96 
circular  compression  in,  50 
compression  in,  52 
during  anesthesia,  354 

operations,  frequency,  353 
graphic  method  of,  104 
in  diagnosis  of  coma,  222 

of  diabetic  coma,  224 
in  life-insurance  examinations,  397 

in  value  of,  399 
in  obstetrics,  384 
in  pregnancy,  frequency  of,  385 

value  of,  384 
in  surgery,  application  of,  353 

value  of,  353 
in  treatment  of  typhoid,  196 
influence    of    intervening    struc- 
tures in,  52,  53 
of  vessel  wall  in,  52 
mechanical  variations  in,  110 
oscillatory  method  of,  104 
palpatory  method  of,  102 

diastolic  pressure  in,  103 

systolic  pressure  in,  102 

personal  equation  of  examiner  in, 

60 
position  of  patient  for,  56 
resistance  of  arterial  walls  in,  53 
scope  of,  89 

subjective  method  of,  107 
technique  of,  65 
visual  method  of,  103 

diastolic  pressure  in,  103 
systolic  pressure  in,  103 
Sphygmometroscope,  107 
multiple,  108 


Spinal  anesthesia,  358 
cord  operations,  357 
puncture,  366 
Stanton's  sphygmomanometer,  71 

disadvantages,  72 
Stenosis,  mitral,  339 
Strain,  effect  of,  on  myocardial  in- 
sufficiency, 325 
Strength,    average  systolic  pressure 

compared  with,  121 
Strychnin,  431 

sulphate,    effect    of,    on    venous 
pressure,  155 
Subjective  method  of  sphygmoma- 
nometry, 107 
Sufficiency,  myocardial,  323 
Surgery,  relation  of  blood-pressure 

to,  347 
Surgical  cases,  353 

operations,  relation  of  blood  com- 
position to,  373 
Swan,  fourth  point  of,  in  diastolic 
pressure,  135 
on  auscultatory  method  of  sphyg- 
momanometry, 99 
Sweating,  450 
SyphiUs,  213 

hypertension  from,  252 
Systolic  murmur  after  exercise,  179 
pressure,  38 

accuracy  of  estimation,  39 
average,         compared         with 

strength,  121 
in  childhood,  115 
in  palpatory  method  of  sphyg- 
momanometry, 102 
in  visual  method  of  sphygmo- 
manometry, 103 
normal  variations  in,  113 
retinal  hemorrhage  and,  376 

Tachycardia,  paroxysmal,  345 
Temperature,  121 

in  arteriosclerosis,  280 
Thiosinamin,  431 
Thoracic  aneurysm,  228 


INDEX 


477 


Thyroid  extract,  28,  432 
Tobacco,  432,  442 
Toxemia,  187 

chronic,  hypertension  from,  249 
of  pregnancy,  391 
Transfusion  of  blood,  373 
Traube-Herring  waves,  127 
Tuberculosis,  159 

accidental  complications  of,  209 
advanced,  210 

charts  of,  212,  213 
effect  of  altitude  on  systolic  pres- 
sure in,  207 
of  exercise  in,  210 
of  open  air  in,  159 
hemorrhage  in,  209 
hypotension  in,  204,  205 

theory  of,  208 
incipient,  406 

low  systolic  pressure  in,  204 
prognosis  of,  207 
pulse  pressure  in,  208 
relation  of  arteriosclerosis  to,  206 
Typhoid  fever,  194 
comphcations,  195 
diastoUc  pressure  in,  195 
hemorrhage  in,  196 
readings  in,  194 
secondary  and  late  effects  of, 

196 
sphygmomanometry    in    treat- 
ment of,  196 

Ulcer,  corneal,  379 

Urea,     excretion     of,     in     chronic 

nephritis,  290 
Urethan,  434 

Urinary    excretion,    pulse    pressure 
and,  301 
findings  in  chronic  nephritis,  301, 
305 

Valvular  cardiac  diseases,  chronic, 
333 
defects,  effect  of,  167 
heart  disease,  227 


Valvular    cardiac    diseases,    insuffi- 
ciency from  excessive  exercise, 
181 
Vascular  tone,  local,  31 

nervous  mechanism  control- 
ling, 31 
Vasoconstrictors,  32 
Vasodilators,  33 

Vasomotor    mechanism    controlling 
blood-pressure,  30 
reflexes,  33 
Vasotonin,  434 

Veins,   maintenance   of   blood-pres- 
sure in,  150 
Venesection,  460 
Venous  pressure,  142,  146 
average,  153 

clinical  importance  of,  153 
diurnal  rhythm  of,  152 
effect  of  alcohol  on,  155 
of  caffein  on,  155 
of  digitalis  group  on,  154 
of  drugs  on,  154 
of  epinephrin  on,  147,  155 
of  exercise  on,  151 
of  external  compression  on, 

152 
of  intravenous  injection  on, 

152 
of  morphin  on,  155 
of    myocardial    degeneration 

on,  152 
of  nitrites  on,  155 
of  pituitrin  on,  155 
of  position  of  part  on,  151 
of  postural  change  on,  328 
of  strychnin  sulphate  on,  155 
factors  influencing,  151 
Gartner's  method  of  measuring 

147 
general  considerations,  146 
high,  in  pleural  effusions,  150 
Howell's  method  of  measuring, 

147 
methods  of  measuring,  146 
normal,  152 


478 


INDEX 


Venous  pressure,  physics  of,  149 
physiology  of,  149 
relation  of  pulse  pressure  to,  in 
heart  cases,  330 
to  pulse  pressure, 
152 
respiratory  variation  in,  152 
Ventricles,  contraction  of,  24 
Veratrum  viride,  434 
Vierordt's     method     of    measuring 

blood-pressure,  63 
Viscosity  of  blood  in  arterial  pres- 
sure, 47 
in  renal  arteriosclerosis,  48 
Visual  method  of  sphygmomanom- 
etry,  103 
diastohc  pressure  in,  103 


Visual  method  of  sphygmomanom- 
etry,  systolic  pressure  in,  103 
Vomiting,  134 
von  Basch's  sphygmomanometer,  63 

Walking,  128 

Water,  447 

White  mercury  sphygmomanometer, 

87,  88 
Woley's  chart  showing  effect  of  age 

on  blood-pressure,  42 

X-RAYS,  29 
YOHIMBIN,  434 

Youth,  energy  expended  by  normal 
heart  in,  16d 


SAUNDERS'  BOOKS 


on 


Pathology,  Physiology 
Histology,  Embryology 
Be^cteriology,   Biology 

W.  B.  SAUNDERS   COMPANY 

WEST  WASHINGTON  SQUARE  PHILADELPHIA 

9.  HENRIETTA  STREET       COVENT  GARDEN,  LONDON 

Prentiss'  Embryology 

Laboratory  Manual  and  Text=Book  of  Embryology.  By  Charles 
W.  Prentiss,  Ph.  D.,  Professor  of  Microscopic  Anatomy,  Northwestern 
University  Medical  School,  Chicago.  Large  octavo  of  400  pages,  with 
368  illustrations,  50  in  colors.     Cloth,  $3.75  net. 

ORIGINAL  ILLUSTRATIONS 

Prof.  Prentiss'  new  work  has  many  features  that  make  it  extremely  vakiable 
to  students  and  teachers  of  vertebrate  or  human  embryology.  It  is  the  only  re- 
cent single  volume  describing  the  chick  a?id  pig  embryos  usually  studied  in  the 
laboratory  ;  and  at  the  same  time  it  gives  a  concise,  systematic  account  of  human 
embryology.  The  descriptions  of  the  embryos  to  be  studied  in  the  laboratory  are 
concise,  yet  they  are  profusely  illustrated,  the  majority  of  the  pictures  being  original. 

It  is  the  only  comparatively  brief  text  in  which  a  large  number  of  original 
dissections  of  pig  and  human  embryos  are  described  and  illustrated,  and  in  which 
directions  are  given  for  making  dissections  of  the  nervous  system,  viscera,  face, 
palate,  and  tongue  of  these  embryos.  Of  the  same  embryos  from  which  series 
of  transverse  sections  ha\'e  been  made,  illustrations  are  given,  showing  the  ex- 
ternal form  and  internal  structure.  The  student  will  thus  be  enabled  to  determine 
the  position  and  plane  of  section  of  each  section  studied.  There  are,  in  addition, 
original  illustrations  of  the  development  of  the  heart,  urogenital  organs,  and  ner- 
vous system.     The  book  contains  368  illustrations,  50  in  colors. 


SAUXDERS'    BOOKS   ON 


MacCallum*s  Pathology 

Text-Book  of  Pathology.     By  W.  G.  MacCallum,  M.  D.,  Professor 

of  Pathology,  College  of  Physicians  and  Surgeons,  New  York.  Octavo 
of  1083  pages,  with  575  original  illustrations,  many  in  colors.  Cloth, 
^7.50  net;     Half  Morocco,  $9.00  net. 

JUST  ISSUED 

Dr.  MacCallum"  s  new  work  presents  pathology  from  an  entirely  new  angle. 
Most  text-books  on  pathology  consider  the  diseases  of  each  organ  separately  under 
the  name  of  the  organ  as  a  heading,  Dr.  MacCallum' s  book,  however,  considers 
pathology  on  the  principle  that  practically  every  pathologic  condition  is  the  direct 
or  indirect  effect  of  an  injury;  that  is,  the  direct  effect  or  the  immediate  or  remote 
reaction  of  the  tissues.  Tumors  alone  cannot  be  brought  under  this  category. 
In  a  word,  this  book  presents  Pathology  based  on  Etiology.  The  treatment  of  the 
subject  is  not  limited  to  anatomic  and  morphologic  descriptions,  but  functional 
disturbances  are  discussed,  as  well  as  those  of  chemical  character,  and  even 
symptoms  are  described.  The  entire  work  is  based  upon  the  study  of  the  material 
itself,  and  practically  all  the  illustrations  were  made  direct  from  those  particular 
specimens  studied. 


Heisler's  Embryology 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
Octavo  volume  of  435  pages,  with  212  illustrations,  32  of  them  in 
colors.     Cloth,  $3.00  net. 

THIRD  EDITION— WITH  212  ILLUSTRATIONS.  32  IN  COLORS 

This  edition  represents  all  the  advances  recently  made  in  the  science  of  em- 
bryology. Many  portions  have  been  entirely  rewritten,  and  a  great  deal  of  new 
and  important  matter  added.  A  number  of  new  illustrations  have  also  been  intro- 
duced and  these  will  prove  very  valuable.  Heisler' s  Embryology  has  become 
a  standard  work. 

G.  Carl  Huber.  M.  D., 

Professor  of  Embryology  at  the  Wistar  Institute,  University  of  Pennsylania. 
"  I  find  this  edition  of    'A  Text-Book  of  Embryology.'  by  Dr.  Heisler,  an  improvement 
on  the  former  one.     The  figures  added  increase  greatly   the  value  of  the  work.     I   am  again 
recommending  it  to  our  students." 


PATHOLOGY 


Mallory  and  Wright*s 
Pathologic  Technique 

New  i6th)  Edition 

Pathologic  Technique.  A  Practical  Manual  for  Workers  in  Patho- 
logic  Histology,  including  Directions  for  the  Performance  of  Autopsies 
and  for  Clinical  Diagnosis  by  Laboratory  Methods.  By  Frank  B. 
Mallory,  M.  D.,  Associate  Professor  of  Pathology,  Harvard  Univer- 
sity; and  James  H.  Wright,  M.  D.,  Pathologist  to  the  Massachusetts 
General  Hospital.  Octavo  of  538  pages,  with  160  illustrations.  Cloth, 
;^300  net. 

In  revising  the  book  for  the  new  edition  the  authors  have  kept  in  view  the 
needs  of  the  laboratory  worker,  whether  student,  practitioner,  or  pathologist,  for 
a  practical  manual  of  histologic  and  bacteriologic  methods  in  the  study  of  patho- 
logic material.  Many  parts  have  been  rewritten,  many  new  methods  have  been 
added,  and  the  number  of  illustrations  has  been  considerably  increased. 

Boston  Medical  eoid  Surgical  Journal 

"  This  manual,  since  its  first  appearance,  has  been  recognized  as  the  standard  guidf*  in  patho- 
logical technique,  and  has  become  well-nigh  indispensable  to  the  laboratory  worker." 


Eyre's   Ba^cteriologlc   Technic 

Bacteriologic  Technic.  A  Laboratory  Guide  for  the  Medical, 
Dental,  and  Technical  Student.  By  J.  W.  H.  Eyre,  M.  D.,  F.  R.  S. 
Edin.,  Director  of  the  Bacteriologic  Department  of  Guy's  Hospital, 
London.     Octavo  of  520  pages,  219  illustrations.  Cloth,  $3.00  net. 

NEW  (2d)  EDITION,  REWRITTEN 

Dr.  Eyre  has  subjected  his  work  to  a  most  searching  revision.  Indeed,  so 
thorough  was  his  revision  that  the  entire  book,  enlarged  by  some  1 50  pages  and 
50  illustrations,  had  to  be  reset  from  cover  to  cover.  He  has  included  all  the 
latest  technic  in  every  division  of  the  subject.  His  thoroughness,  his  accuracy,  his 
attention  to  detail  make  his  work  an  important  one.  He  gives  clearly  the  technic 
for  the  bacteriologic  examination  of  water,  sewage,  air,  soil,  milk  and  its  products, 
meats,  etc.  And  he  gives  you  good  technic — methods  attested  by  his  own  large 
experience.  To  any  one  interested  in  this  line  of  endeavor  the  new  edition  of 
Dr.  Eyre's  work  is  indispensable.     The  illustrations  are  as  practical  as  the  text. 


SAUNDERS'  BOOKS  ON 


Mallory's 
Pathologic   Histology 

Pathologic  Histology.  By  Frank  B.  Mallory,  M.  D.,  Associate 
Professor  of  Pathology,  Harvard  University  Medical  School.  Octavo 
of  677  pages,  with  497  figures  containing  683  original  illustrations,  124 
in  colors.  Cloth,  $5.50  net ;   Half  Morocco,  ^7.00  net. 

'     REPRINTED  IN  THREE  MONTHS 

Dr.  Mallory  here  presents  patholo^^y  from  the  morphologic  point  of  view.  He 
presents  his  subject  biologically,  first  by  ascertaining  the  cellular  elements  out 
of  which  the  various  lesions  are  built  up  ;  then  he  traces  the  development  of  the 
lesions  from  the  simplest  to  the  most  complex.  He  so  presents  pathology  that 
you  are  able  to  trace  backward  from  any  given  end-result,  such  as  sclerosis  of  an 
organ  (cirrhosis  of  the  liver,  for  example),  through  all  the.  various  acute  lesions 
that  may  terminate  in  that  particular  end-result  to  the  primal  catise  of  the  lesion. 
The  illustratunis  are  most  beautiful. 

Dr.  W.  G.   MacCallum,    Coiuf/ibia  University 

"  I  have  looked  over  the  book  and  think  the  plan  is  admirably  carried  out  and  that  the 
book  supplies  a  need  we  have  felt  very  much.     I  shall  be  very  glad  to  recommend  it." 


Howeirs  Physiology 


A  Text=Book  of  Physiology.  By  William  H.  Howell,  Ph.D., 
M.  D.,  Professor  of  Physiology  in  the  Johns  Hopkins  Universit)',  Balti- 
more, Md,     Octavo  of  1020  pages,  306  illustrations.     Cloth,  ^4.00  net. 

THE  NEW  (6th)  EDITION 

Dr.  Howell  has  had  many  years  of  experience  as  a  teacher  of  physiology  in 
several  of  the  leading  medical  schools,  and  is  therefore  exceedingly  well  fitted  to 
write  a  text-book  on  this  subject.  Main  emphasis  has  been  laid  upon  those  facts 
and  views  which  will  be  directly  helpful  in  the  practical  branches  of  medicine.  At 
the  same  time,  however,  sufficient  consideration  has  been  given  to  the  experimen- 
tal side  of  the  science.  The  entire  literature  of  physiology  has  been  thoroughly 
digested  by  Dr.  Howell,  and  the  important  views  and  conclusions  introduced  into 
his  work.      Illustrations  have  been  most  freely  used. 

The  Lancet,  London 

"  This  is  one  of  the  best  recent  text-books  on  physiology,  and  we  warmly  commend  it  to  the 
attention  of  students  who  desire  to  obtain  by  reading  a  general,  all-round,  yet  concise  survey  of 
the  scope,  facts,  theories,  and  speculations  that  make  up  its  subject  matter." 


BACTERIOLOGY  AND   HISTOLOGY. 


McFarland's  Pathogenic 
Bacteria    and    Protozoa 

Pathogenic  tJacteria  and  Protozoa.  By  Joseph  McFarland,  M.D.» 
Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia.  Octavo  of  807  pages,  finely  illustrated. 
Cloth,  $4.00  net. 

NEW  (8th)  EDITION.  ENLARGED 

Dr.  McFarland's  book  teaches  you  the  laboratory  technic  with  reference  to 
the  needs  of  medical  students  and  practitioners.  It  brings  each  micro-organism 
into  a  historic,  geographic,  biologic,  and  pathologic  setting.  It  dwells  upon  the 
anatomic  and  physiologic  disturbances  referable  to  the  various  micro-organisms. 
It  describes  the  lesions  occasioned  by  the  different  micro-organisms.  It  explains 
such  methods  of  diagnosis  and  treatment  as  grow  out  of  a  knowledge  of  microbiology. 

H.  B.  Anderson,  M.  D.. 

Professor  of  Pathology  and  Bacteriology,   Trinity  Medical  College,  Toronto. 
"The  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommendingit  to  the  students 
of  Trinity  College." 

The  Lancet,  London 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable," 

HilFs  Histology  and  Organography 

A  Manual  of  Histology  and  Organography.  By  Charles  Hill, 
M.  D.,  formerly  Assistant  Professor  of  Histology  and  Embryology, 
Northwestern  University,  Chicago.  i2mo  of  483  pages,  337  illustra- 
tions.    Cloth,  ^2.25  net. 

THE   NEW    (3d)   EDITION 

Dr.  Hill's  work  is  characterized  by  a  completeness  of  discussion  rarely  met  in 
a  book  of  this  size.     Particular  consideration  is  given  the  mouth  and  teeth. 

Pennsylvania  Medical  Journal 

"  It  is  arranged  in  such  a  manner  as  to  be  easy  of  access  and  comprehension.     To  anj 
contemplating  the  study  of  histology  and  organography  we  would  commend  this  work." 


SAUNDERS-  BOOKS  ON 


McFarland*s   Pathology 


A  Text=Book  of  Pathology.  By  Joseph  McFarland,  M.  D.,  Pro- 
fessor of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical  College 
of  Philadelphia.  Octavo  of  856  pages,  with  437  illustrations,  many  in 
colors.     Cloth,  ^5.00  net;   Half  Morocco,  $6.50  net. 

THE   NEW    (2d)    EDITION 

You  cannot  successfully  treat  disease  unless  you  have  a  practical,  ilinicaX 
knowledge  of  the  pathologic  changes  produced  by  disease.  For  this  purpose  Dr. 
McFarland' s  work  is  well  fitted.  It  was  written  with  just  such  an  end  in  view — to 
furnish  a  ready  means  of  acquiring  a  thorough  training  in  the  subject,  a  training 
such  as  would  be  of  daily  help  in  your  practice.  For  this  edition  every  page  has 
been  gone  over  most  carefully,  correcting,  omitting  the  obsolete,  and  adding  the 
new.  Some  sections  have  been  entirely  rewritten.  You  will  find  it  a  book  well 
worth  consulting,  for  it  is  the  work  of  an  authority. 

St.  Paul  Medical  Journal 

"  It  is  safe  to  say  tliat  there  are  few  who  are  better  qualified  to  give  a  resume  of  the  modem 
views  on  this  subject  than  McFarland.     The  subject-matter  is  thoroughly  up  to  date." 

Boston  Medical  and  Surgical  Journal 

"  It  contains  a  great  mass  of  well-classified  facts.  One  of  the  best  sections  is  that  on  the 
special  pathology  of  the  blood." 


McFarland*s 

Biolog'y:  Medical  and  General 

Biology:  Medical  and  General — By  Joseph  McFarland,  M.  D., 
Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical  Col- 
lege of  Phila.      i2mo,  457  pages,  160  illustrations.     Cloth,  ^1.75  net. 

NEW  (2d)   EDITION 

This  work  is  both  a  general  and  tnedkal  biology.  The  former  because  it  dis- 
cusses the  peculiar  nature  and  reaciions  of  living  substance  generally;  the  latter 
because  particular  emphasis  is  laid  on  those  subjects  of  special  interest  and  value 
in  the  study  and  practice  of  medicine.  The  illustrations  will  be  found  of  great 
assistance. 

Frederic  P.  Gorham,  A.  M.,  Brown  University. 

"  I  am  greatly  jilcasid  with  it.  Perhaps  the  highest  praise  which  I  can  give  the  book  is  to 
say  that  it  more  nearly  approaclies  the  course  I  am  now  giving  in  general  biology  than  any 
other  work." 


PATHOLOGY 


Stengel  ^  Fox's  Pathology 

Pathology.  By  Alfred  Stengel,  M.  D.,  Sc.  D.,  Professor  of  JMcdi- 
cine,  University  of  Pennsylvania;  and  Herbert  Fox,  M.  D.,  Director 
of  the  Pepper  Laboratories  of  Clinical  Medicine,  University  of  Pennsyl- 
vania. Octavo  of  1045  pages,  with  468  text-illustrations,  many  in 
colors,  and  15  colored  plates.     Cloth,  $6.00  net ;  Half  Morocco,  $7.50  net. 

NEW  (6th)  EDITION.  REWRITTEN 

This  new  (6th)  edition  is  virtually  a  new  work.  It  has  been  rewritten  through- 
out, reset  in  new  type,  and  a  larger  type  page  used.  New  matter  equivalent  to 
175  pages  has  been  added  and  some  75  new  illustrations,  many  of  them  in  colors. 
The  work  is  a  handsome  volume  of  over  1000  pages.  In  the  first  portions,  de- 
voted to  general  pathology,  the  sections  on  inflammation,  retrogressive  processes, 
disorders  of  nutrition  and  metabolism,  general  etiology,  and  diseases  due  to  bac- 
teria were  wholly  rewritten  or  \ery  largely  recast.  A  new  section  on  transmissible 
diseases  was  added;  the  terata  were  included,  with  a  synoptical  chapter  on  terat- 
ology. The  glands  of  internal  secretion  were  given  a  separate  chapter,  and  new 
chapters  on  the  pathology  of  eye,  ear,  and  skin  were  added. 


Stiles^  Human  Physiology 

JUST  ISSUED 

The  simplicity,  the  clearness  with  which  Dr.  Stiles  presents  this  difficult 
subject  makes  the  work  decidedly  valuable  as  a  text-book  for  High  Schools  and 
General  Colleges.      The  text  is  illustrated  in  Dr.  Stiles'  usual  striking  way. 

i2mo  of  405  pages,  illustrated.  By  Percy  Goldthwait  Stiles,  Assistant  Professor  of  Physiology 
at  Harvard  University.  Cloth,  $1.50  net. 

Stiles'  Nutritional  Physiolog;y 

NEW  (2d)   EDITION 

Prof  Stiles'  work  opens  with  a  brief  but  adequate  presentation  of  the  physiology 
of  free-living  cells  and  leads  up  to  the  more  complex  function  in  man.  It  discusses 
the  role  each  organ,  each  secretion  plays  in  the  physiology  of  nutrition — in  the 
transformation  of  energy. 

i2mo  of  208  pages,  illustrated.     By  Pei«cy  G.  Stiles,  Harvard  University.     Cloth,  $1.25  net. 

Stiles'  The  Nervous  System 

This  new  book  is  really  a  physiology  and  anatomy  of  the  nervous  system, 
emphasizing  the  means  of  conserving  nervous  energy.  You  get  chapters  on  the 
minute  structure,  reflexes,  afferent  nervous  system,  neuromuscular  system  and 
fatigue,  autonomic  system,  the  cerebrum  and  human  development,  emotion,  sleep, 
dreams,  causes  of  nervous  impairment,  neurasthenia,  hygiene. 

i2mo  of  230  pages,  illustrated.     By  Percy  Goldthwait  Stiles,  Harvard  University.    Cloth,  ^1.25  net. 


SAUNDERS'    BOOKS   ON 


Jordan's 
General   Bacteriolo£(y 

A  Text=Book  of  General  Bacteriology.  By  Edwin  O.  Jordan,  Ph.D., 
Professor  of  Bacteriology  in  the  University  of  Chicago  and  in  Rush 
Medical  College.     Octavo  of  667  pages,  illustrated. 

JUST  OUT— NEW  (5th)  EDITION 

Professor  Jordan's  work  embraces  the  entire  field  of  bacteriology,  the  non- 
pathogenic as  well  as  the  pathogenic  bacteria  being  considered,  giving  greater 
emphasis,  of  course,  to  the  latter.  There  are  extensive  chapters  on  methods  of 
studying  bacteria,  including  staining,  biochemical  tests,  cultures,  etc. ;  on  the 
development  and  composition  of  bacteria  ;  on  enzymes  and  fermentation-products; 
on  the  bacterial  production  of  pigment,  acid  and  alkali  ;  and  on  ptomains  and 
toxins.  Especially  complete  is  the  presentation  of  the  serum  treatment  of  gonor- 
rhea, diphtheria,  dysentery,  and  tetanus.  The  relation  of  bovine  to  human 
tuberculosis  and  the  ocular  tuberculin  reaction  receive  extensive  consideration. 

This  work  will  also  appeal  to  academic  and  scientific  students.  It  contains 
chapters  on  the  bacteriology  of  plants,  milk  and  milk-products,  air,  agriculture, 
water,  food  preservatives,  the  processes  of  leather  tanning,  tobacco  curing,  and 
vinegar  making  ;  the  relation  of  bacteriology  to  household  administration  and  to 
sanitary  engineering,  etc. 

Prof.  Severance  Burra^e,  Associate  Professor  of  Sanitary  Science,  Purdue  University. 

"  I  am  much  impressed  with  the  completeness  and  accuracy  of  the  book.  It  certainly 
covers  the  ground  more  completely  than  any  other  American  book  that  I  have  seen." 


Wadsworth's  Postmortems 

Postmortem  Examinations.  By  William  S.  Wadsworth,  M.  D., 
Coroner's  Physician  of  Philadelphia.  Octavo  of  600  pages,  with  304 
original  illustrations.  Cloth,  $6.00  net;    Half  Morocco,  $7.50  net. 

BASED  ON  4000  POSTMORTEMS 

This  new  work  is  based  on  Dr.  Wadsworth' s  sixteen  years'  constant  study  of 
the  human  body  and  of  some  4000  postmortems.  So  far  as  possible  the  principles 
are  presented  rather  than  rules.  The  actual  technic  is  explained  in  detail — far 
more  fully  than  in  any  other  work.  Many  errors,  commonly  accepted  as  facts,  are 
pointed  out  and  corrected.  A  strong  feature  is  the  great  attention  given  to  the 
interpretation  of  findings. 

The  i/iustrations  are  actual  photographs  taken  by  Dr.  \\'adsworth  himself. 
They  are  photographs  of  the  fresh  cadaver — not  of  preserved  specimens. 

Anatomists,  surgeons,  medical  men  of  all  departments  will  find  a  great  deal 
of  real  value.  To  those  who  are  called  upon  to  perform  postmortem  examina- 
tions this  new  book  is  indispensable  because  it  gives  them  the  new  technic,  the 
new  interpretation  of  findings,  the  last  word  on  the  subject. 


PATHOLOG\ 


GET  ^  »  THE  NEW 

THE  BEST  /\  m  6  r  1  C  Si  n  standard 

Illustrated   Dictionary 

New  ^8th)  Edition— 1500  New  Terms 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches ;  with  over  100  new  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "  The 
American  Pocket  Medical  Dictionary."  Large  octavo,  1137  pages, 
bound  in  full  flexible  leather.  Price,  ;^4.50  net;  with  thumb  index, 
$5.00  net. 

IT  DEFINES  ALL  THE  NEW  WORDS— IT  IS  UP  TO  DATE 

The  American  Illustrated  Medical  Dictionary  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  new  terms  are  Uve, 
active  words,  taken  right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.  It  makes  a  feature 
of  the  derivation  or  etymology  of  the  words.  In  some  dictionaries  the  etymology 
occupies  only  a  secondary-  place,  in  many  cases  no  derivation  being  given  at  all. 
In  the  American  Illustrated  practically  every  word  is  given  its    derivation. 

Every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a  word 
quickly. 

The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the  greatest  help  in 
assembling  anatomic  facts.  In  them  are  classified  for  quick  study  all  the  neces- 
sary information  about  the  various  structures. 

Every  word  is  given  its  definition — a  definition  that  defines  in  the  fewest  pos- 
sible words.  In  some  dictionaries  hundreds  of  words  are  not  defined  at  all, 
referring  the  reader  to  some  other  source  for  the  information  he  wants  at  once. 

Howard  A,  Kelly,  ^.Yi.,  Johns  Hopkins  Univej-sify,  Baltimore. 

"  The  American  Illustrated  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such 
convenient  size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.),  Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


SAUNDERS'    BOOKS   ON 


Wells*  Chemical  Pathology 


Chemical  Pathology. — Being  a  Discussion  of  General  Pathology 
from  the  Standpoint  of  the  Chemical  Processes  Involved.  By  H, 
Gideon  Wells,  Ph.  D.,  M.  D.,  Assistant  Professor  of  Pathology  in  the 
University  of  Chicago.     Octavo  of  6i6  pages.     Cloth,  $3.25  net. 

NEW  (2d)  EDITION 

Dr.  Wells'  work  is  written  for  the  physician,  for  those  engaged  in  research  in 
pathology  and  physiologic  chemistry,  and  for  the  medical  student.  In  the  intro- 
ductory chapter  are  discussed  the  chemistry  and  physics  of  the  animal  cell,  giving 
the  essential  facts  of  ionization,  diffusion,  osmotic  pressure,  etc.,  and  the  relation 
of  these  facts  to  cellular  activities.  Special  chapters  are  devoted  to  Diabetes  and 
to  Uric-acid  Metabolism  attd  Gout. 

Wm.  H.  Welch.  M.  D. 

Professor  of  Pathology,  Johns  Hopkins  U?nversity. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my    students." 

Lusk*s 
Elements  of  Nutrition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk,  Ph.  D., 
Professor  of  Physiology  at  Cornell  Medical  School.  Octavo  volume 
of  302  pages.     Cloth,  ;^3.oo  net, 

THE  NEW  (2d)  EDITION— TRANSLATED  INTO  GERMAN 

Prof.  Lusk  presents  the  scientific  foundations  upon  which  rests  our  knowledge 
of  nutrition  and  metabolism,  both  in  health  and  in  disease.  There  are  special 
chapters  on  the  metabolism  of  diabetes  and  fever,  and  on  purin  metabolism. 
The  work  will  also  prove  valuable  to  students  of  animal  dietetics  at  agricultural 
stations. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University. 
"  I  shall  recommend  it  highly  to  my  students.     It  is  a  comfort  to  have  such  a  discussion 
of  the  subject  in  English." 


HISTOLOGY.  II 


Daugherty's 
Economic   Zo61og(y 

Economic  Zoology.  By  L.  S.  Daugherty,  M.  S.,  Ph.  D.,  Professor 
of  Zoology,  State  Normal  School,  Kirksville,  Mo.,  and  M.  C.  Daugh- 
erty, author  with  Jackson  of  "  Agriculture  Through  the  Laboratory 
and  School  Garden."  Part  I:  Field  and  Laboratory  Guide.  i2mo  of 
237  pages,  interleaved.  Cloth,  ;^  1.25  net.  Part  II:  Principles.  i2mo 
of  406  pages,  illustrated.     Cloth,  $2.00  net. 

ILLUSTRATED 


There  is  no  other  book  just  like  this.  Not  only  does  it  give  the  salient  facts 
of  structural  zoology  and  the  development  of  the  various  branches  of  animals,  but 
also  the  natural  history — the  life  and  habits — thus  showing  the  interrelations  (rf 
structure,  habit,  and  environment.  In  a  word,  it  gives  the  principles  of  zoology 
and  their  actual  application.  The  economic  phase  is  emphasized. 
Part  I — the  Field  and  Laboratory  Gtiide — is  designed  for  practical  instruction  in 
the  field  and  laboratory.  To  enhance  its  value  for  this  purpose  blank  pages  arc 
inserted  for  notes. 


DrewV 

Invertebrate  Zoology 

A  Laboratory  Manual  of  Invertebrate  Zoology.  By  Oilman  A. 
Drew,  Ph.D.,  Assistant  Director  at  Marine  Biological  Laboratory,  Woods 
Hole,  Mass.  With  the  aid  of  Former  and  Present  Members  of  the  Zoological 
Staff  of  Instructors.      i2moof  213  pages.  Cloth,  $1.25  net. 

NEW  (2d)   EDITION 

The  subject  is  presented  in  a  logical  way,  and  the  type  method  of  study  has 
been  followed,  as  this  method  has  been  the  prevailing  one  for  many  years. 

Prof.  Allison  A.  Smyth,  Jr.,  Virginia  Polytechnic  Institute 

"  I  think  it  is  the  best  laboratory  manual  of  zoology  I  have  yet  seen.  The  large  number 
of  forms  dealt  with  makes  the  work  applicable  to  almost  any  locality." 


SAL'A'BAV^'S'    BOOKS    OX 


Norris*   Cardiac   Pathology 

studies    in   Cardiac  Pathology.     By  George  \V.  Norris,    M.D. 
Associate  in  Medicine  at  the  University  of  Pennsylvania.     Large  octavo 
of  235  pages,  with  85  superb  illustrations.     Cloth,  $5.00  net. 

SUPERB    ILLUSTRATIONS 

The  illustrations  are   superb.      Each  ilkistration  is  accompanied  by  a  detailed 
description;  besides,  there  is  ample  letter  press  supplementing  the  pictures. 

Boston  Medical  and  Surgfical  Journal 

"The  illustrations  are  arranged  in  such  a  way  as  to  illustrate  all  the  common  and  many  of 
the  rare  cardiac  lesions,  and  the  accompanying  descriptive  text  constitutes  a  fairly  continuous 
didactic  treatise." 


McConneirs  Pathology 

A  Manual  of  Pathology.  By  Guthrie  McConnell,  M.  D.,  As- 
sistant Surgeon,  Medical  Reserve  Corps,  U.  S.  Navy.  i2mo  of  523 
pages,  with  170  illustrations.     Flexible  leather,  ^2.50  net. 

NEW  (2d)  EDITION 
Dr.  McConnell  has   discussed  his  subject  with  a  clearness  and  precision  of 
style  that  make  the  work  of  great  assistance  to  both  student  and  practitioner. 
The  illustrations  have  been  introduced  for  their  practical  value. 

New  York  State  Journal  of  Medicine 

"  The  book  treats  the  subject  of  pathology  with  a  thoroughness  lacking  in  many  works  of 
greater  pretension.  The  illustrations — many  of  them  original — are  profuse  and  of  exceptional 
excellence." 


McConneirs  Pathology  and  Bacteriology  *'°lt?d%"nu 

Pathology  and  Bacteriology  for  Dental  Students.  By  Guthrie 
McConnell,  M.  D.,  Assistant  Surgeon,  Medical  Reserve  Corps,  U.  S.  N. 
i2mo  of  309  pages,  illustrated.      Cloth,  ;i>2.25  net. 

ILLUSTRATED 

This  work  is  written  expressly  for  dentists  and  dental  students,  emphasizing 
throughout  the  application  of  pathology  and  bacteriology  in  dental  studv  and  prac- 
tice. There  are  chapters  on  disordeis  of  metabolism  and  circulation;  retro- 
gressive processes,  cell  division  inflammation  and  regeneration,  granulomas,  pro- 
gressive processes,  tumors,  special  mouth  pathology,  sterilization  and  disinfection, 
bacteriologic  methods,  specific  micro-organisms,  infection  and  immunity,  and 
laboratory  technic. 


HISTOLOGY.  13 


Dtirck  anb  Hektoen*s 

Special    Pathologic    Histology 

Atlas  and  Epitome  of  Special  Pathologic  Histology.     By  Dr.  H. 

DiJRCK,  of  Munich.  Edited,  with  additions,  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  two  parts. 
Part  I. — Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts.  120 
colored  figures  on  62  plates,  and  158  pages  of  text.  Part  II. — Liver, 
Urinary  and  Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and 
Bones.  123  colored  figures  on  60  plates,  and  192  pages  of  text.  Per 
part :   Cloth,  ;^3.00  net.     In  Saunders'  Hand-Atlas  Series. 

The  great  value  of  these  plates  is  that  they  represent  in  the  exact  colors  the  effect 
of  the  stains,  which  is  of  such  great  importance  for  the  differentiation  of  tissue. 
The  text  portion  of  the  book  is  admirable,  and,  while  brief  it  is  entirely  satisfac- 
tory in  that  the  leading  facts  are  stated,  and  so  stated  that  the  reader  feels  he  has 
grasped  the  subject  extensively. 

William  H.  Welch,  M.  D., 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore. 

"  I  consider  Diircks  'Atlas  of  Special  Pathologic  Histology,'  edited  by  Hektoen,  a  very 
useful  book  for  students  and  others.     The  plates  are  admirable." 

Sobotta  and  Huberts 
Human  Histology 

Atlas  and  Epitome  of  Human  Histology.  By  Privatdocent  Dr. 
J.  Sobotta,  of  Wiirzburg,  Edited,  with  additions,  by  G.  Carl  Huber, 
M.  D.,  Professor  of  Histology  and  Embryology  in  the  University  of 
Michigan,  Ann  Arbor.  With  214  colored  figures  on  80  plates,  68 
text-illustrations,  and  248  pages  of  text.  Cloth,  ;^4.50  net.  In 
Saunders'  Hand-Atlas  Series. 

INCLUDING   MICROSCOPIC  ANATOMY 

The  work  combines  an  abundance  of  well-chosen  and  most  accurate  illustra- 
tions, with  a  concise  text,  and  in  such  a  manner  as  to  make  it  both  atlas  and  text- 
book. The  great  majority  of  the  illustra-tions  were  made  from  sections  prepared 
from  human  tissues,  and  always  from  fresh  and  in  every  respect  normal  specimens. 
The  colored  lithographic  plates  have  been  produced  with  the  aid  of  over  thirty  colors. 

Boston  Medical  and  Surgical  Journal 

"  In  color  and  proportion  they  are  characterized  by  gratifying  accuracy  and  lithographic 
beauty." 


14  SAUNDERS'    BOOKS    ON 

Bosanquet  on  Spirochaetes 

Spirochaetes :  A  Review  of  Recent  Work,  with  Some  Original  Ob- 
servations. By  W.  Cecil  Bosanquet,  M.D.,  Fellow  of  the  Royal  Col- 
lege of  Physicians,  London.    Octavo  of  1 52  pages,  illustrated.  ^2.50  net. 

ILLUSTRATED 

This  is  a  complete  and  authoritative  monograph  on  the  spirochaetes,  giving 
morphology,  pathogenesis,  classification,  staining,  etc.  Pseudospirochaetes  are 
also  considered,  and  the  entire  text  well  ilkistrated.  The  high  standing  of  Dr. 
Bosanquet  in  this  field  of  study  makes  this  new  work  particularly  valuable. 


Levy  and  Klemperer*s 
Clinical  Bacteriology 

The  Elements  of  Clinical  Bacteriology.  By  Drs.  Ernst  Levy  and 
Felix  Klemperer,  of  the  University  of  Strasburg.  Translated  and 
edited  by  Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  volume  of  440  pages,  fully  illustrated. 
Cloth,  ^2.50  net. 

S.  Solis-Cohen,  M.  D., 

Professor  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

"  I  consider  it  an  excellent  book.     I  have  recommended  it  in  speaking  to  my  students." 


Lehmann,  Neumann,  anb 
Weaver's  Bacteriology 

Atlas  and  Epitome  of  Bacteriology :  including  a  Text-Book  of 
Special  Bacteriologic  Diagnosis.  By  Prof.  Dr.  K.  B.  Lehmann 
and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  From  the  Second  Revised  and 
Enlarged  Gennan  Edition.  Edited,  with  additions,  by  G.  H.  Weaver, 
M.  D.,  As.sistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical 
College,  Chicago.  In  two  parts.  Part  I. — 632  colored  figures  on  69 
lithographic  plates.  Part  II. — 51 1  pages  of  text,  illustrated.  Per  part: 
Cloth,  ;^2.50  net.     /;/  Saunders   Hand-Atlas  Series. 


PA  THOLOG  V,  BA CTERIOL OG  V,  AND  PA  THOL OGY  15 


Durck  and  Hektoen's  General  Pathologic  Histology 

Atlas  and  Epitome  of  General  Patholocic  Histolo(;y.  By  Pr. 
Dr.  H.  Durck,  of  Munich.  Edited,  with  additions,  by  Ludvig  Hek- 
TOEN,  M.  D.,  Professor  of  Pathology  in  Rush  Medical  College,  Chicago. 
172  colored  figures  on  77  lithographic  plates,  ^^  text-cuts,  many 
in  colors,  and  353  pages.  Cloth,  $5.00  net.  In  Saunders' Hand-Atlas 
Series. 

American  Text-Book  of  Physiology  second  Edition 

American  Text-Book;  of  Physiology.  In  two  volumes.  Edited  by 
William  H.  Howell,  Ph.  D.,  M.D.,  Professor  of  Physiology  in  the  Johns 
Hopkins  University,  Baltimore,  Md.  Two  royal  octavos  of  about  600 
pages  each,  illustrated.  Per  volume:  Cloth,  $3.00  net;  Half  Morocco, 
$4.25  net. 

"  The  work  will  stand  as  a  work  of  reference  on  physiology.  To  him  who  desires  to  know, 
the  status  of  modern  physiology,  who  expects  to  obtain  suggestions  as  to  further  physio- 
logic inquiry,  we  know  of  none  in  English  which  so  eminently  meets  such  a  demand." — 
The  Medical  News. 

Warren's   Pathology   and  Therapeutics        second  Edition 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Med- 
ical School.  Octavo,  873  pages,  136  relief  and  lithographic  illustrations, 
33  in  colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis 
and  a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net; 
Half  Morocco,  $6.50  net. 

Raymond's  Physiology  New  (3d)  Edition 

Human  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D.,  Pro- 
fessor of  Physiology  and  Hygiene,  Tong  Island  College  Hospital,  New 
York.     Octavo  of  685  pages,  with  444  illustrations.     Cloth,  $3.50  net. 

"  The  book  is  well  gotten  up  and  well  printed,  and  may  be  regarded  as  a  trustworthy 
guide  for  the  student  and  a  useful  work  of  reference  for  the  genera:  practitioner.  The 
illustrations  are  numerous  and  are  well  executed." — The  Lancet,  London. 

Bohm,  Davidoff.  anZ  Huber's  Histology  f^hion 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
By  Dr.  A.  A.  Bohm  and  Dr.  M.  Von  Davidoff,  of  Munich,  and  G. 
Carl  Huber,  M.  D.,  Professor  of  Embryology  at  the  Wistar  Institute, 
University  of  Pennsylvania.  Octavo  of  528  pages,  with  361  beautiful 
original  illustrations.      Flexible  cloth,   $3.50  net. 


l6  BACTERIOLOGY,    PHYSIOLOGY,    AND  HISTOLOGY. 


Ball's    BacteriolO£(y  seventh  Edition,  Revised 

Essentials  of  Bacteriology  :  being  a  concise  and  systematic  intro- 
duction to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.  D.,  Late 
Bacteriologist  to  St.  Agnes'  Hospital.  Philadelphia.  i2mo  of  289  pages, 
with  135  illustrations,  some  in  colors.  Cloth,  $1.00  net.  In  Saunders* 
Question-  Compeiid  Series. 

"  The  technic  with  regard  to  media,  staining,  mounting,  and  tlie  like  is  culled  from  the 
latest  authoritative  works." — T/ie  Medical  Times,  New  York. 

Bud^ett*S    PhysiolO^  New  (4th)  Edition 

Essentials  of  Physiology.  Prepared  especially  for  Students  of  Medi- 
cine, and  arranged  with  questions  following  each  chapter.  By  Sidney 
P.  BuDGETT,  M.  D.,  formerly  Professor  of  Physiology,  Washington  Uni- 
versity, St.  Louis.  Revised  by  Harold  E.  B.  Pardee,  M.  D.,  Listructor 
in  Physiology,  Columbia  University  (College  of  Physicians  and  Surgeons), 
New  York.  lamo  volume  of  206  pages,  illustrated.  Cloth,  $1.00  net. 
Saunders'  Question-Compend  Scries. 

"He  has  an  excellent  conception  of  his  subject.  .  .  It  is  one  of  the  most  satislactory 
books  of  this  class" — Utiiversity  of  Pennsylvania  Medical  Bulletin. 

Leroy's  Histology  New  (4th)  Edition 

Essentials  of  Histology.     By  Louis  Leroy,  M.  D.,  Professor  of 

Histology  and  Pathology,  Vanderbilt  University,  Nashville,  Tennessee. 

i2mo,  263  pages,  with  92  original  illustrations.     Cloth,  $1.00  net.     In 

Saunders'  Question-  Compend  Series. 

"  The  work  in  its  present  form  stands  as  a  model  of  what  a  student's  aid  should  be  ;  and 
we  unhesitatingly  say  that  the  practitioner  as  well  would  find  a  glance  through  the  book 
of  lasting  benefit." — Tke  Medical  World,  Philadelphia. 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  M.  D.,  Assistant  Professor  of  Materia  Medica  and  Therapeutics, 
and  Walter  A.  Wells,  M.D.,  Demonstrator  of  Laryngology,  Georgetown 
University,  Washington,  D.  C.  i2mo,  534  pages.  Flexible  leather, 
$2.50  net;  thumb  indexed,  $3.00  net. 

American  Pocket  Medic&l  Dictionary       ^ew  (9th  Edition 

American  Pocket  Medical  Dictionary.  Edited  by  ^V.  A.  New- 
man Dorland,  M.  D.,  Editor  *' American  Illustraied  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  75  extensive  tables. 
693  pages.  Flexible  leather,  with  gold  edges,  $1.00  net;  with  patent 
thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  of 
the  Jefferson  Medical  College,  Philadelphia. 


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